hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|GA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Stephens County Hospital,2024-07-01,2.0.0,Stephens County Hospital,"163 Hospital Road Toccoa, GA 30577",586001667,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|Aetna|Commercial|negotiated_dollar,standard_charge|Aetna|Commercial|negotiated_percentage,standard_charge|Aetna|Commercial|negotiated_algorithm,estimated_amount|Aetna|Commercial,standard_charge|Aetna|Commercial|methodology,additional_payer_notes|Aetna|Commercial,standard_charge|AMERIGROUP|MEDICAID|negotiated_dollar,standard_charge|AMERIGROUP|MEDICAID|negotiated_percentage,standard_charge|AMERIGROUP|MEDICAID|negotiated_algorithm,estimated_amount|AMERIGROUP|MEDICAID,standard_charge|AMERIGROUP|MEDICAID|methodology,additional_payer_notes|AMERIGROUP|MEDICAID,standard_charge|BCBS|Commercial|negotiated_dollar,standard_charge|BCBS|Commercial|negotiated_percentage,standard_charge|BCBS|Commercial|negotiated_algorithm,estimated_amount|BCBS|Commercial,standard_charge|BCBS|Commercial|methodology,additional_payer_notes|BCBS|Commercial,standard_charge|CARESOURCE|MEDICARE|negotiated_dollar,standard_charge|CARESOURCE|MEDICARE|negotiated_percentage,standard_charge|CARESOURCE|MEDICARE|negotiated_algorithm,estimated_amount|CARESOURCE|MEDICARE,standard_charge|CARESOURCE|MEDICARE|methodology,additional_payer_notes|CARESOURCE|MEDICARE,standard_charge|CIGNA|Commercial|negotiated_dollar,standard_charge|CIGNA|Commercial|negotiated_percentage,standard_charge|CIGNA|Commercial|negotiated_algorithm,estimated_amount|CIGNA|Commercial,standard_charge|CIGNA|Commercial|methodology,additional_payer_notes|CIGNA|Commercial,standard_charge|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|,standard_charge|MEDICAID|methodology,additional_payer_notes|MEDICAID|,standard_charge|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|,standard_charge|MEDICARE|methodology,additional_payer_notes|MEDICARE|,standard_charge|PEACHSTATE|MEDICAID|negotiated_dollar,standard_charge|PEACHSTATE|MEDICAID|negotiated_percentage,standard_charge|PEACHSTATE|MEDICAID|negotiated_algorithm,estimated_amount|PEACHSTATE|MEDICAID,standard_charge|PEACHSTATE|MEDICAID|methodology,additional_payer_notes|PEACHSTATE|MEDICAID,standard_charge|UHC|Commercial|negotiated_dollar,standard_charge|UHC|Commercial|negotiated_percentage,standard_charge|UHC|Commercial|negotiated_algorithm,estimated_amount|UHC|Commercial,standard_charge|UHC|Commercial|methodology,additional_payer_notes|UHC|Commercial,standard_charge|WELLCARE|MEDICAID|negotiated_dollar,standard_charge|WELLCARE|MEDICAID|negotiated_percentage,standard_charge|WELLCARE|MEDICAID|negotiated_algorithm,estimated_amount|WELLCARE|MEDICAID,standard_charge|WELLCARE|MEDICAID|methodology,additional_payer_notes|WELLCARE|MEDICAID,standard_charge|min,standard_charge|max,additional_generic_notes
BENTYL (dicyclomine) 10MG/5ML SYR: 1OZ,292223,CDM,250,RC,,,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
NM CAPTOPRIL 50 MG.,297899,CDM,250,RC,78990,HCPCS,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
OXYGEN 9-15 LPM,3020,CDM,270,RC,,,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
DECANNULATION PLUG,30036,CDM,270,RC,,,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
CATH IV INTROCAN 16GA X 1.25,496311,CDM,270,RC,,,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
CATH IV INTROCAN 14GA X 1.25,4996302,CDM,270,RC,,,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
ARTERIAL SPECIMEN COLLECT,1836600,CDM,300,RC,36600,HCPCS,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
S. PNEUMO INDIVIDUAL SEROTYPE IGG,1882219,CDM,300,RC,86317,HCPCS,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8,15.09,
A lab test to screen for evidence of vaginal infection,1887209,CDM,300,RC,87210,HCPCS,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.36,9,
ARTERIAL SPECIMEN COLLECT,3036600,CDM,300,RC,G0001,HCPCS,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
OXYGEN @ 9-15 LPM,30017,CDM,412,RC,,,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
OXYGEN 9-15,53345,CDM,412,RC,,,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,,,,Other,Not Separately reimbursable,3.22,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,33.11,,2.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.22,9,
ROCEPHIN (ceftriaxone) 2GM VIAL,300166,CDM,636,RC,J0696,HCPCS,Outpatient,,,10,6,,8.5,85,,6.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8,80.03,,6.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,90,,7.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.8,88,,7.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.47,9,
POTASSIUM CHLOR PB 20MEQ/ 50ML PREMIXED,304787,CDM,636,RC,J3480,HCPCS,Outpatient,,,10.03,6.02,,8.53,85,,6.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.03,80.03,,6.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.03,90,,7.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.83,88,,7.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.11,9.03,
AUGMENTIN (amox/clav acid) 500MG TAB,29732,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
NIZORAL (KETOCONAZOLE) 200MG TAB,29756,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
CIPRO (ciprofloxacin) 250MG TAB,29803,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
TUSSAR SF : 1OZ,292298,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
INACTIVE,295041,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.05,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
NASAL SALINE DROPS 15ML,295044,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
BANALG LINAMENT 60ML,297008,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
HYDROCORT CRM 1% 30GM,297025,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
PREPARATION H OINT 1OZ,297045,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
VISINE EYE DROPS 15ML,297738,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
SULF-10 OPTH OINT 3.5GM,297813,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
NEO SYNEPHRINE (PHENYLEPH) 1/4%NASALSPRA,297904,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
ORAJEL 15GM,298002,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
SUCRETS LOZ. 24'S,298009,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.05,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
CALADRYL LOTION 2.5OZ,298018,CDM,250,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
ALPHAKERI BATH OIL 4 OZ,298029,CDM,270,RC,,,Outpatient,,,10.05,6.03,,8.54,85,,6.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.04,80.03,,6.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.05,90,,7.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.23,32.15,,2.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.84,88,,7.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.33,33.11,,2.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.23,9.05,
URE-NA 15G PACKET,302630,CDM,250,RC,B4155,HCPCS,Outpatient,,,10.08,6.05,,8.57,85,,6.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,8.07,80.03,,6.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1.07,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,9.07,90,,7.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.07,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.87,88,,7.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1.07,9.07,
CALMOSEPTINE OINT 71G,297108,CDM,250,RC,,,Outpatient,,,10.2,6.12,,8.67,85,,6.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.28,32.15,,2.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.16,80.03,,6.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,90,,7.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.28,32.15,,2.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.28,32.15,,,Other,Not Separately reimbursable,8.98,88,,7.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.38,33.11,,2.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.28,9.18,
REQUIP (ropinirole) 0.25MG TAB,29498,CDM,250,RC,,,Outpatient,,,10.25,6.15,,8.71,85,,6.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.2,80.03,,6.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.23,90,,7.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.3,32.15,,,Other,Not Separately reimbursable,9.02,88,,7.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.39,33.11,,2.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.3,9.23,
AMOXICILLIN 125MG/5ML SUSP: 80ML,292314,CDM,250,RC,,,Outpatient,,,10.25,6.15,,8.71,85,,6.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.2,80.03,,6.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.23,90,,7.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.02,88,,7.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.39,33.11,,2.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.3,9.23,
MELLARIL-S (THIORIDAZINE) 5MG/ML 1OZ,295052,CDM,250,RC,,,Outpatient,,,10.25,6.15,,8.71,85,,6.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.2,80.03,,6.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.23,90,,7.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.02,88,,7.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.39,33.11,,2.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.3,9.23,
XYLOCAINE 5% (LIDOCAINE) : OINTMENT 1APP,297100,CDM,250,RC,,,Outpatient,,,10.25,6.15,,8.71,85,,6.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.2,80.03,,6.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.23,90,,7.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.02,88,,7.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.39,33.11,,2.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.3,9.23,
OXYCONTIN (oxycodone-SR) 20MG TAB,299018,CDM,250,RC,,,Outpatient,,,10.25,6.15,,8.71,85,,6.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.2,80.03,,6.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.23,90,,7.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.25,,,,Other,Not Separately reimbursable,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.02,88,,7.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.39,33.11,,2.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.3,9.23,
ROXANOL (morphine)  20 MG/ML  0.5ML DOSE,303423,CDM,250,RC,,,Outpatient,,,10.25,6.15,,8.71,85,,6.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.2,80.03,,6.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.23,90,,7.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.3,32.15,,2.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.02,88,,7.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.39,33.11,,2.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.3,9.23,
BLOOD GLUCOSE CHECK,82962,CDM,300,RC,82962,HCPCS,Outpatient,,,10.25,6.15,,8.71,85,,6.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.2,80.03,,6.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,9.23,90,,7.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.02,88,,7.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.94,9.23,
PAXIL CR (paroxetine) 12.5MG TAB,29436,CDM,250,RC,,,Outpatient,,,10.3,6.18,,8.76,85,,7.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.24,80.03,,6.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.27,90,,7.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.06,88,,7.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.41,33.11,,2.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.31,9.27,
CARAFATE (sucralfate) 1GM/10ML SUSP: 1OZ,292323,CDM,250,RC,,,Outpatient,,,10.3,6.18,,8.76,85,,7.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.24,80.03,,6.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.27,90,,7.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.06,88,,7.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.41,33.11,,2.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.31,9.27,
BLS MILEAGE (PER MILE),530380,CDM,540,RC,A0425,HCPCS,Outpatient,,,10.3,6.18,,8.76,85,,7.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.24,80.03,,6.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.27,90,,7.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.06,88,,7.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.41,33.11,,2.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.31,9.27,
ALS MILEAGE (PER MILE),530390,CDM,540,RC,A0425,HCPCS,Outpatient,,,10.3,6.18,,8.76,85,,7.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.24,80.03,,6.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.27,90,,7.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.06,88,,7.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.41,33.11,,2.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.31,9.27,
NONCOVERED MILEAGE,530391,CDM,549,RC,A0888,HCPCS,Outpatient,,,10.3,6.18,,8.76,85,,7.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.24,80.03,,6.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.27,90,,7.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.31,32.15,,2.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.06,88,,7.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.41,33.11,,2.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.31,9.27,
NEW SKIN LIQUID BANDAGE 30 ML,298071,CDM,250,RC,,,Outpatient,,,10.4,6.24,,8.84,85,,7.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.34,32.15,,2.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.32,80.03,,6.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.36,90,,7.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.34,32.15,,2.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.34,32.15,,2.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.15,88,,7.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.44,33.11,,2.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.34,9.36,
LAMICTAL (lamotrigine) 25 MG TAB,291011,CDM,250,RC,,,Outpatient,,,10.55,6.33,,8.97,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.39,32.15,,2.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.44,80.03,,6.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.39,32.15,,2.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.55,,,,Other,Not Separately reimbursable,3.39,32.15,,2.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,88,,7.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.49,33.11,,2.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.39,9.5,
FLOXIN (OFLOXACIN) 200MG TAB,29238,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
PEPCID (FAMOTIDINE) 40MG TAB,29773,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
ZANTAC (RANITIDINE) 300MG TAB,29788,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
MISC DRUG 9,29902,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
ALDOMET 250MG/5ML LIQ : 1OZ,292202,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
KEFLEX (CEPHALEXIN) 100MG/ML DROPS 10ML,294020,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
TRI-VI-SOL : 30ML,294037,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
BRONDECON : 1OZ,295014,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
BRONKOLIXIR : 1 OZ,295021,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
KENALOG CRM (triamcinolone) 0.025%  80GM,297014,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
POLYSPORIN (BACI/POLYMIX) OINT 15GM,297043,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
ATROP 1%OPTH STERIUNIT 2M,297740,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
NEO SYNEPHRINE (PHENYLEPH) 1/4%NASALDROP,297905,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
DILAUDID (HYDROmorphone) SUPP 3MG,299013,CDM,250,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
TES-TAPE W/VSP,292028,CDM,270,RC,,,Outpatient,,,10.56,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.45,80.03,,6.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,90,,7.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,,,,Other,Not Separately reimbursable,3.4,32.15,,2.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.29,88,,7.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.5,33.11,,2.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.4,9.5,
AMPICILLIN : 500MG VIAL,293130,CDM,636,RC,J0290,HCPCS,Outpatient,,,10.57,6.34,,8.98,85,,7.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.46,80.03,,6.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.51,90,,7.61,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.57,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.3,88,,7.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,9.51,
PULMICORT RESPULES 0.25MG/2ML,292093,CDM,250,RC,,,Outpatient,,,10.65,6.39,,9.05,85,,7.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.42,32.15,,2.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.52,80.03,,6.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.59,90,,7.67,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.42,32.15,,2.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.42,32.15,,2.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.37,88,,7.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.53,33.11,,2.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.42,9.59,
PULMICORT RESPULES 0.5 MG/2ML,292095,CDM,250,RC,,,Outpatient,,,10.65,6.39,,9.05,85,,7.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.42,32.15,,2.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.52,80.03,,6.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.59,90,,7.67,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.42,32.15,,2.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.65,,,,Other,Not Separately reimbursable,3.42,32.15,,2.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.37,88,,7.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.53,33.11,,2.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.42,9.59,
HISTEX HC SYR : 1OZ,292257,CDM,250,RC,,,Outpatient,,,10.75,6.45,,9.14,85,,7.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.46,32.15,,2.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.6,80.03,,6.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.68,90,,7.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.46,32.15,,2.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.75,,,,Other,Not Separately reimbursable,3.46,32.15,,2.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.46,88,,7.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.56,33.11,,2.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.46,9.68,
INSPRA (eplerenone) 25 MG,291092,CDM,250,RC,,,Outpatient,,,10.85,6.51,,9.22,85,,7.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.49,32.15,,2.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.68,80.03,,6.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.77,90,,7.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.49,32.15,,2.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.85,,,,Other,Not Separately reimbursable,3.49,32.15,,2.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.55,88,,7.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.59,33.11,,2.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.49,9.77,
CLEOCIN (clindamycin ): 900MG VIAL,293543,CDM,250,RC,S0077,HCPCS,Outpatient,,,10.87,6.52,,9.24,85,,7.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.49,32.15,,2.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.7,80.03,,6.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.78,90,,7.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.49,32.15,,2.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.49,32.15,,2.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.57,88,,7.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.6,33.11,,2.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.49,9.78,
STER WATER IRG 250ML,304009,CDM,258,RC,,,Outpatient,,,10.9,6.54,,9.27,85,,7.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.5,32.15,,2.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.72,80.03,,6.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.81,90,,7.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.5,32.15,,2.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.9,,,,Other,Not Separately reimbursable,3.5,32.15,,2.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.59,88,,7.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.61,33.11,,2.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.5,9.81,
RISPERDAL (risperidone) 1MG TAB,29669,CDM,250,RC,,,Outpatient,,,10.95,6.57,,9.31,85,,7.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.52,32.15,,2.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.76,80.03,,7.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.86,90,,7.89,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.52,32.15,,2.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.95,,,,Other,Not Separately reimbursable,3.52,32.15,,2.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.64,88,,7.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.63,33.11,,2.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.52,9.86,
TAMIFLU (oseltamivir) 45 MG CAP,29875,CDM,250,RC,,,Outpatient,,,11,6.6,,9.35,85,,7.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,80.03,,7.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.9,90,,7.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,,,,Other,Not Separately reimbursable,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.68,88,,7.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.64,33.11,,2.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.54,9.9,
CATHETER FOLEY 12FR 10CC LF 2-WAY,49398,CDM,270,RC,,,Outpatient,,,11,6.6,,9.35,85,,7.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,80.03,,7.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.9,90,,7.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.68,88,,7.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.64,33.11,,2.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.54,9.9,
CATHETER FOLEY 14FR 10CC LF 2-WAY,49399,CDM,270,RC,,,Outpatient,,,11,6.6,,9.35,85,,7.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,80.03,,7.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.9,90,,7.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,,,,Other,Not Separately reimbursable,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.68,88,,7.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.64,33.11,,2.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.54,9.9,
CATHETER FOLEY 16FR 10CC LF 2-WAY,49400,CDM,270,RC,,,Outpatient,,,11,6.6,,9.35,85,,7.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.8,80.03,,7.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.9,90,,7.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,,,,Other,Not Separately reimbursable,3.54,32.15,,2.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.68,88,,7.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.64,33.11,,2.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.54,9.9,
LORTAB ELIX 3.3MG/ 5ML(hydrocod/acet),292320,CDM,250,RC,,,Outpatient,,,11.03,6.62,,9.38,85,,7.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.55,32.15,,2.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.83,80.03,,7.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.93,90,,7.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.55,32.15,,2.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.03,,,,Other,Not Separately reimbursable,3.55,32.15,,2.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.71,88,,7.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.65,33.11,,2.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.55,9.93,
BIAXIN (clarithromycin) 250MG TAB,29072,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.08,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
NITROSTAT (nitroglycerin) 0.4MG TAB 25'S,29390,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.08,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
CEFTIN (CEFUROXIME) 250MG TAB,29821,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.08,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
ROBITUSSIN AC (GUAIFEN/COD) SOLN: 1 OZ,292275,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.08,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
PEN VK (penicillin) 250MG/5ML SUSP:200ML,294026,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.08,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
BACITRACIN OINT 15GM,297007,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.08,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
MYOFLEX CREAM 60GM,297031,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.08,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
BACTRICIN OPTH OINT 3.5GM,297501,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
NEO SYNEPHRINE (PHENYLEPH) 1/2% NASAL,297906,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
CETACAINE SPRAY UNIT DOSE,298046,CDM,250,RC,,,Outpatient,,,11.08,6.65,,9.42,85,,7.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.87,80.03,,7.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.97,90,,7.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.56,32.15,,2.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.75,88,,7.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.67,33.11,,2.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.56,9.97,
NEO SYNEPHRINE (PHENYLEPH) 1% NASAL(XS),297907,CDM,250,RC,,,Outpatient,,,11.2,6.72,,9.52,85,,7.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.6,32.15,,2.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.96,80.03,,7.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.08,90,,8.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.6,32.15,,2.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.6,32.15,,2.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.86,88,,7.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.71,33.11,,2.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.6,10.08,
RISPERDAL (RISPERIDONE) 3MG TAB,29676,CDM,250,RC,,,Outpatient,,,11.23,6.74,,9.55,85,,7.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.61,32.15,,2.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.99,80.03,,7.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.11,90,,8.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.61,32.15,,2.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.61,32.15,,2.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.88,88,,7.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.72,33.11,,2.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.61,10.11,
COREG CR (carvedilol) 20MG,29274,CDM,250,RC,,,Outpatient,,,11.3,6.78,,9.61,85,,7.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.63,32.15,,2.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.04,80.03,,7.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.17,90,,8.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.63,32.15,,2.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.63,32.15,,2.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.94,88,,7.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.74,33.11,,2.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.63,10.17,
HYDROCORT CRM 2.5%  28gm,297096,CDM,250,RC,,,Outpatient,,,11.3,6.78,,9.61,85,,7.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.63,32.15,,2.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.04,80.03,,7.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.17,90,,8.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.63,32.15,,2.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.63,32.15,,2.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.94,88,,7.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.74,33.11,,2.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.63,10.17,
TESSALON PERLES (benzonatate) 200MG CAP,291104,CDM,250,RC,,,Outpatient,,,11.44,6.86,,9.72,85,,7.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.68,32.15,,2.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.16,80.03,,7.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.3,90,,8.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.68,32.15,,2.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.68,32.15,,2.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.07,88,,8.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.79,33.11,,3.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.68,10.3,
PRAVACHOL (pravastatin) 40MG TAB,29880,CDM,250,RC,,,Outpatient,,,11.45,6.87,,9.73,85,,7.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.68,32.15,,2.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.16,80.03,,7.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.31,90,,8.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.68,32.15,,2.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.68,32.15,,2.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.08,88,,8.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.79,33.11,,3.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.68,10.31,
AMOXIL (amoxicillin) 200MG/5ML  50ML,291089,CDM,250,RC,,,Outpatient,,,11.5,6.9,,9.78,85,,7.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.7,32.15,,2.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.2,80.03,,7.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.35,90,,8.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.7,32.15,,2.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.7,32.15,,2.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.12,88,,8.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.81,33.11,,3.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.7,10.35,
NEO SYNEPHRINE (phenyleph) 10% OPTH:U/D,303961,CDM,250,RC,,,Outpatient,,,11.52,6.91,,9.79,85,,7.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.7,32.15,,2.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.22,80.03,,7.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.37,90,,8.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.7,32.15,,2.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.52,,,,Other,Not Separately reimbursable,3.7,32.15,,2.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.14,88,,8.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.81,33.11,,3.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.7,10.37,
CIPRO (ciprofloxacin ) 500MG TAB,29804,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
DECADRON (DEXAMETH) 0.5MG/5ML ELIX: 1OZ,292221,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
E.E.S. 200MG/5ML : 100 ML,294017,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
GENTAMICIN CR. 0.1% 15GM,297046,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
ILOTYCIN OPTH OINT 3.5 GM,297506,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
SULF-10 OPTH SOLN 10ML,297757,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
OTRIVIN NASAL SPRAY : 20 ML,297909,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
CHLORASEPTIC SPRAY 6OZ,298028,CDM,250,RC,,,Outpatient,,,11.59,6.95,,9.85,85,,7.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.28,80.03,,7.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.43,90,,8.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.59,,,,Other,Not Separately reimbursable,3.73,32.15,,2.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.2,88,,8.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.84,33.11,,3.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.73,10.43,
ROBINUL (glycopyrrolate) FORTE 2MG TAB,291063,CDM,250,RC,,,Outpatient,,,11.65,6.99,,9.9,85,,7.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.75,32.15,,3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.32,80.03,,7.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.49,90,,8.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.75,32.15,,3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.65,,,,Other,Not Separately reimbursable,3.75,32.15,,3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.25,88,,8.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.86,33.11,,3.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.75,10.49,
VYTORIN 10/10/(ezetim/simvastat) TAB,29882,CDM,250,RC,,,Outpatient,,,11.75,7.05,,9.99,85,,7.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.4,80.03,,7.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.58,90,,8.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.34,88,,8.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,33.11,,3.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.78,10.58,
VYTORIN 10/20 (ezetimibe/simvastat) TAB,29883,CDM,250,RC,,,Outpatient,,,11.75,7.05,,9.99,85,,7.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.4,80.03,,7.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.58,90,,8.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.34,88,,8.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,33.11,,3.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.78,10.58,
VYTORIN 10/40 (ezetimibe/simvastat) TAB,29884,CDM,250,RC,,,Outpatient,,,11.75,7.05,,9.99,85,,7.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.4,80.03,,7.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.58,90,,8.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.34,88,,8.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,33.11,,3.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.78,10.58,
BENZOIN TINCT SPRAY,298005,CDM,250,RC,,,Outpatient,,,11.75,7.05,,9.99,85,,7.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.4,80.03,,7.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.58,90,,8.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.34,88,,8.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,33.11,,3.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.78,10.58,
BENZOIN TINCT SWABSTICK 10%,298025,CDM,250,RC,,,Outpatient,,,11.75,7.05,,9.99,85,,7.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.4,80.03,,7.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.58,90,,8.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.34,88,,8.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,33.11,,3.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.78,10.58,
VYTORIN 10/80 (ezetimibe/simvastat) TAB,2910766,CDM,250,RC,,,Outpatient,,,11.75,7.05,,9.99,85,,7.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.4,80.03,,7.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.58,90,,8.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.34,88,,8.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,33.11,,3.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.78,10.58,
LEU DOSE,22450,CDM,636,RC,Q9969,HCPCS,Outpatient,,,11.75,7.05,,9.99,85,,7.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.4,80.03,,7.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.19,102,,,fee schedule,Pays at 102% of CMS APC rate,10.58,90,,8.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.19,100,,,fee schedule,Pays at 100% of CMS APC rate,3.78,32.15,,3.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.34,88,,8.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,33.11,,3.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.78,10.58,
ZOCOR (simvastatin) 40MG TAB,29659,CDM,250,RC,,,Outpatient,,,11.81,7.09,,10.04,85,,8.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.8,32.15,,3.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.45,80.03,,7.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.63,90,,8.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.8,32.15,,3.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.8,32.15,,3.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.39,88,,8.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.91,33.11,,3.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.8,10.63,
STROMECTOL (ivermectin) 3MG TAB,304147,CDM,250,RC,,,Outpatient,,,11.93,7.16,,10.14,85,,8.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.84,32.15,,3.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.55,80.03,,7.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.74,90,,8.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.84,32.15,,3.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.84,32.15,,3.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.5,88,,8.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.95,33.11,,3.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.84,10.74,
DEMEROL (meperidine): 25MG/ML CARP,299007,CDM,636,RC,J2175,HCPCS,Outpatient,,,11.99,7.19,,10.19,85,,8.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.79,90,,8.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.55,88,,8.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,10.79,
DEMEROL (meperidine): 50MG INJ,299008,CDM,636,RC,J2175,HCPCS,Outpatient,,,11.99,7.19,,10.19,85,,8.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.79,90,,8.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.55,88,,8.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,10.79,
DEMEROL (meperidine) : 75MG INJ,299009,CDM,636,RC,J2175,HCPCS,Outpatient,,,11.99,7.19,,10.19,85,,8.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.79,90,,8.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.55,88,,8.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,10.79,
NAMENDA (memantine) 10MG TAB,29191,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
IMITREX (sumatriptan) 25 MG TABLET,29281,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
LIPITOR (atorvastatin) 10MG TAB,29336,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
NEXIUM {esomeprazole} 40MG *** Non-formu,29361,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
PAXIL CR (paroxetine) 25 MG TAB,29438,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
LYRICA (pregabalin) 25MG CAP,29688,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
LAMICTAL (lamotrigine) 100 MG TAB,291012,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
MOBIC (meloxicam) 15 MG TAB,291068,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
TONOPEN (opth pressure pen) DEVICE,293512,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
AMOXICILLIN 125/5 : 150ML,294003,CDM,250,RC,,,Outpatient,,,12,7.2,,10.2,85,,8.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.6,80.03,,7.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,8.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.86,32.15,,3.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,88,,8.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.97,33.11,,3.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.86,10.8,
FLU VACCINE CHILD/SENIOR,62005,CDM,636,RC,Q2038,HCPCS,Outpatient,,,12.1,7.26,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.68,80.03,,7.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.89,90,,8.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.65,88,,8.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.89,
TENORMIN (atenolol) 5MG/10 ML,29564,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
DURICEF (cefadroxil) 500MG CAP,29603,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
HABITROL (nicotine) 7MG PATCH,292077,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
THEO-ORGANIDIN ELIX : 1OZ,292289,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
DEXTROSE 50%: 50ML VIALS,293065,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
SODIUM CHLORIDE: 50meq/20ML INJ,293162,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
PITOCIN/SYNTOCIN (oxytocin) 10 UNIT VIAL,293179,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
BACT. NS 30 ML VIAL,293234,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
HUMULIN R:     UNITS INJ,293260,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
HUMULIN N INSULIN,293261,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
NOVOLIN NPH INSULIN,293263,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
NOVOLIN LENTE INSULIN,293264,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.11,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
NOVOLIN REG INSULIN,293269,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.11,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
BUMEX (bumetanide) 0.25MG/ML 2ML INJ,293273,CDM,250,RC,S0171,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
HUMULIN 50/50 INSULIN,293275,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
BUPRENEX (buprenorphine) 0.3MG INJ,293307,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
HUMULIN L INSULIN,293325,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
UNIPEN (nafcillin) : 500MG VIAL,293387,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
TYLENOL (acetaminophen) DROPS- WT BASED,294305,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
AMICAR (aminocap ) 1.25GM/5ML LIQ : 5ML,295123,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
MAGIC MOUTHWASH 2 OZ,295129,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
FEMTAC 150MG/10ML LIQUID,295698,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
REG PORK U-100 INSULIN,296030,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
REG U-100:    UNITS INSULIN,296031,CDM,250,RC,J1820,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
NPH U-100 INSULIN,296032,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
NOVOLIN 70/30 INSULIN,296041,CDM,250,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
SEMILENTE U-100 INSULIN,296070,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
NEODECADRON  5ML OPHTH,297751,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
AFRIN NOSE DROPS : 15ML,297902,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
NISENTAL : 40MG,299033,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.11,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
AMYTAL : 500MG INJECTION,299056,CDM,250,RC,,,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
SODIUM CHLORIDE INJ : 5ML,293163,CDM,272,RC,A4216,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
SODIUM CHLORIDE INJ : 10ML,293164,CDM,272,RC,A4216,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
ANCEF(CEFAZOLIN) : 25MG,293003,CDM,636,RC,J0690,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,10.9,
ATROPINE 0.4MG/0.5ML : AMP,293020,CDM,636,RC,J0461,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,10.9,
BENADRYL (DIPHENHYDRAMINE) 50MG/MLSYRING,293024,CDM,636,RC,J1200,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,10.9,
COLCHICINE 1MG/2ML INJ,293046,CDM,636,RC,J0760,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
CYANOCOBALAMIN : 100MCG INJ,293050,CDM,636,RC,J3420,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.33,10.9,
DECADRON (DEXAMETHASONE) 4MG/ML INJ,293052,CDM,636,RC,J1100,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.13,10.9,
DRAMAMINE (dimenhydramine) : 50MG INJ,293071,CDM,636,RC,J1240,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
FLUOROURACIL : 500MG INJ,293084,CDM,636,RC,J9190,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.84,10.9,
LASIX (furosemide): 20MG/2ML INJ,293095,CDM,636,RC,J1940,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.58,10.9,
MANNITOL 25% : 50ML VIAL,293106,CDM,636,RC,J2150,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,5.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.26,10.9,
PHENERGAN (promethazine) 25MG INJ,293137,CDM,636,RC,J2550,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.48,10.9,
PHENOBARBITAL: 30MG INJ,293141,CDM,636,RC,J2560,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,36.97,102,,,fee schedule,Pays at 102% of CMS APC rate,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.97,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.34,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.69,36.25,
POTASSIUM CHLORIDE: 2 MEQ/ML INJ 10ML,293144,CDM,636,RC,J3480,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.11,10.9,
SOLU CORTEF (hydrocortisone) 100MG INJ,293166,CDM,636,RC,J1720,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.69,17.67,
"HEPARIN 10,000 UNITS/ML INJ",293237,CDM,636,RC,J1644,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.11,,,,Other,Not Separately reimbursable,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.28,10.9,
HEPARIN LOCK FLUSH PED 10 UNITS/ML,293241,CDM,636,RC,J1642,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.11,,,,Other,Not Separately reimbursable,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.02,10.9,
HUMULIN 70/30 INSULIN,293262,CDM,636,RC,J1815,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,10.9,
AMPICILLIN : 250MG VIAL,293282,CDM,636,RC,J0290,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,10.9,
XYLOCAINE (LIDOCAINE) 1% INJ 5ML  UD,293302,CDM,636,RC,J2001,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,10.9,
XYLOCAINE (lidocaine )  2% INJ 5 ML U/D,293303,CDM,636,RC,J2001,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,10.9,
AMPICILLIN : 125MG VIAL,293317,CDM,636,RC,J0290,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,10.9,
POTASSIUM CHL : 2MEQ PER EACH 100ML LVF,293339,CDM,636,RC,J3480,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.11,10.9,
FRAGMIN (DALTEPARIN) 2500UNIT,293361,CDM,636,RC,J1645,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
PENICILLIN: 1 MILL UNITS VIAL,293367,CDM,636,RC,J2510,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
DIPTH&TET TOX ABSORB PED,296054,CDM,636,RC,90702,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.89,32.15,,3.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.01,33.11,,3.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.89,10.9,
DILAUDID (HYDROmorphone) INJ: 2MG,299014,CDM,636,RC,J1170,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.02,10.9,
DILAUDID (HYDROmorphone) INJ: 4MG,299016,CDM,636,RC,J1170,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.02,10.9,
MORPHINE : 10MG INJ,299029,CDM,636,RC,J2270,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,10.9,
MORPHINE : 15MG INJ,299030,CDM,636,RC,J2270,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,10.9,
MORPHINE :  2MG INJ,299035,CDM,636,RC,J2270,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,10.9,
MORPHINE : 4MG INJ,299036,CDM,636,RC,J2270,HCPCS,Outpatient,,,12.11,7.27,,10.29,85,,8.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.69,80.03,,7.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.9,90,,8.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.66,88,,8.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,10.9,
DIOVAN (valsartan) 160MG TAB,29179,CDM,250,RC,,,Outpatient,,,12.3,7.38,,10.46,85,,8.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.95,32.15,,3.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.84,80.03,,7.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.07,90,,8.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.95,32.15,,3.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,3.95,32.15,,3.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.82,88,,8.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.07,33.11,,3.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.95,11.07,
OCEAN (SOD CHLORIDE) NASAL SPRAY,297919,CDM,250,RC,,,Outpatient,,,12.3,7.38,,10.46,85,,8.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.95,32.15,,3.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.84,80.03,,7.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.07,90,,8.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.95,32.15,,3.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.3,,,,Other,Not Separately reimbursable,3.95,32.15,,3.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.82,88,,8.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.07,33.11,,3.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.95,11.07,
COLCRYS (cholchicine)  0.6MG TAB,29125,CDM,250,RC,,,Outpatient,,,12.33,7.4,,10.48,85,,8.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.96,32.15,,3.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.87,80.03,,7.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.1,90,,8.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.96,32.15,,3.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.33,,,,Other,Not Separately reimbursable,3.96,32.15,,3.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.85,88,,8.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.08,33.11,,3.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.96,11.1,
RETROVIR (zidovudine) 50mg/ 5ml LIQ  1OZ,293560,CDM,250,RC,,,Outpatient,,,12.33,7.4,,10.48,85,,8.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.96,32.15,,3.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.87,80.03,,7.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.1,90,,8.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.96,32.15,,3.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.33,,,,Other,Not Separately reimbursable,3.96,32.15,,3.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.85,88,,8.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.08,33.11,,3.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.96,11.1,
TYLENOL (acetamin) SUSP- WT BASED DOSING,294304,CDM,250,RC,,,Outpatient,,,12.35,7.41,,10.5,85,,8.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.97,32.15,,3.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.88,80.03,,7.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.12,90,,8.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.97,32.15,,3.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.35,,,,Other,Not Separately reimbursable,3.97,32.15,,3.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.87,88,,8.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.09,33.11,,3.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.97,11.12,
PREDNISOLONE 5MG/5ML : 1OZ,292254,CDM,250,RC,,,Outpatient,,,12.36,7.42,,10.51,85,,8.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.97,32.15,,3.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.89,80.03,,7.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.12,90,,8.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.97,32.15,,3.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.36,,,,Other,Not Separately reimbursable,3.97,32.15,,3.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.88,88,,8.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.09,33.11,,3.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3.97,11.12,
ZOFRAN (ondansetron) 4MG/2ML INJ,29643,CDM,250,RC,J2405,HCPCS,Outpatient,,,12.4,7.44,,10.54,85,,8.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.92,80.03,,7.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.16,90,,8.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.91,88,,8.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,11.16,
XOPENEX (levalbuterol)1.25MG/3ML SOLN,292117,CDM,250,RC,,,Outpatient,,,12.45,7.47,,10.58,85,,8.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4,32.15,,3.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.96,80.03,,7.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,90,,8.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4,32.15,,3.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4,32.15,,3.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.96,88,,8.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.12,33.11,,3.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4,11.21,
ARICEPT (donepezil)10MG TAB,29110,CDM,250,RC,,,Outpatient,,,12.5,7.5,,10.63,85,,8.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,80.03,,8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,88,,8.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.14,33.11,,3.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.02,11.25,
BIAXIN XL (clarithromycin ) 500MG TAB,29121,CDM,250,RC,,,Outpatient,,,12.5,7.5,,10.63,85,,8.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,80.03,,8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,88,,8.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.14,33.11,,3.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.02,11.25,
LYRICA (pregabalin) 50MG CAP,29744,CDM,250,RC,,,Outpatient,,,12.5,7.5,,10.63,85,,8.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,80.03,,8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,88,,8.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.14,33.11,,3.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.02,11.25,
GEODON (ZIPRASIDONE) 40MG CAP,293489,CDM,250,RC,,,Outpatient,,,12.5,7.5,,10.63,85,,8.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,80.03,,8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,88,,8.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.14,33.11,,3.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.02,11.25,
ACULAR PF(ketorolac)*SINGLE DOSE* 0.4ML,297774,CDM,250,RC,,,Outpatient,,,12.5,7.5,,10.63,85,,8.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10,80.03,,8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.02,32.15,,3.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,88,,8.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.14,33.11,,3.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.02,11.25,
XYLOCAINE (LIDOCAINE) 1% INJ 10ML UD,293523,CDM,636,RC,J2001,HCPCS,Outpatient,,,12.5,7.5,,10.63,85,,8.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10,80.03,,8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11,88,,8.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,11.25,
NEWBORN BILI PANEL,1882249,CDM,300,RC,82247,HCPCS,Outpatient,,,12.55,7.53,,10.67,85,,8.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.04,80.03,,8.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,11.3,90,,9.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.04,88,,8.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,11.3,
BIAXIN (clarithromycin) 500MG TAB,29068,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
FLOXIN (OFLOXACIN) 300MG TAB,29240,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
ZOVIRAX (acyclovir) 800MG TAB,29794,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
TRILAFON (PERPHENAZINE) INJ,293255,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
COCCIDIOIDIN SKIN TEST,296078,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.62,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
MAMMOL CREAM 25GM,297035,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.62,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
NEOSPORIN (BACI/NEO/POLYMIX) TUBE 15GM,297047,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
AMYTAL : 100MG AMPS,299054,CDM,250,RC,,,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.06,32.15,,3.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.18,33.11,,3.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.06,11.36,
AMINOPHYLLINE: 500MG/20ML INJ,293009,CDM,636,RC,J0280,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,10.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.1,11.36,
DEPO-TESTOSTERONE 100MG/ML INJ,293063,CDM,636,RC,J1071,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,11.36,
METHERGINE (methylergonovine)0.2MG/MLINJ,293108,CDM,636,RC,J2210,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,21.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.1,21.09,
NUBAIN (nalbuphine) 10MG/ML INJ,293129,CDM,636,RC,J2300,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.87,11.36,
HEPARIN 1000 UNITS/ML 10ML,293238,CDM,636,RC,J1644,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.28,11.36,
FLUSH-HEPARIN LOCK 100 UNITS/ML CENTRAL,293342,CDM,636,RC,J1642,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.02,11.36,
FLUSH-HEPARIN LOCK 500units/5ML PICC-prn,293578,CDM,636,RC,J1642,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.02,11.36,
FLUSH-HEPARIN LOCK100 units/ml PICC-1400,293579,CDM,636,RC,J1642,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.02,11.36,
DILAUDID 2MG MDV 20ML,294091,CDM,636,RC,J2175,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,11.36,
DEMEROL (meperidine) : 100MG INJ,299010,CDM,636,RC,J2175,HCPCS,Outpatient,,,12.62,7.57,,10.73,85,,8.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.1,80.03,,8.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.36,90,,9.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.11,88,,8.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,11.36,
CIPRO (ciprofloxacin) 750MG TAB,29847,CDM,250,RC,,,Outpatient,,,12.67,7.6,,10.77,85,,8.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.07,32.15,,3.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.14,80.03,,8.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.4,90,,9.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.07,32.15,,3.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.07,32.15,,3.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.15,88,,8.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.2,33.11,,3.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.07,11.4,
OCCULT BLOOD,1882270,CDM,300,RC,82270,HCPCS,Outpatient,,,12.71,7.63,,10.8,85,,8.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.17,80.03,,8.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.46,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,11.44,90,,9.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.46,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.18,88,,8.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.04,11.44,
"URINE SODIUM, RANDOM",1884300,CDM,300,RC,84300,HCPCS,Outpatient,,,12.71,7.63,,10.8,85,,8.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.17,80.03,,8.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,11.44,90,,9.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.18,88,,8.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.35,11.44,
"BILIRUBIN, TRANSCUT",1888720,CDM,301,RC,88720,HCPCS,Outpatient,,,12.71,7.63,,10.8,85,,8.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.09,32.15,,3.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.17,80.03,,8.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,11.44,90,,9.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.09,32.15,,3.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.09,32.15,,3.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.18,88,,8.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.21,33.11,,3.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.09,11.44,
"RAST, FIRE ANTS, IGE  (MAYO)",1885998,CDM,300,RC,86003,HCPCS,Outpatient,,,12.75,7.65,,10.84,85,,8.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.2,80.03,,8.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,11.48,90,,9.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.22,88,,8.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,11.48,
BRETHINE (terbutaline) 5MG TAB,29078,CDM,250,RC,,,Outpatient,,,12.8,7.68,,10.88,85,,8.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.12,32.15,,3.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.24,80.03,,8.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.52,90,,9.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.12,32.15,,3.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.8,,,,Other,Not Separately reimbursable,4.12,32.15,,3.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.26,88,,9.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.24,33.11,,3.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.12,11.52,
GROUND MILEAGE,530425,CDM,540,RC,A0425,HCPCS,Outpatient,,,12.88,7.73,,10.95,85,,8.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.14,32.15,,3.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.31,80.03,,8.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.59,90,,9.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.14,32.15,,3.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.14,32.15,,3.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.33,88,,9.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.26,33.11,,3.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.14,11.59,
PHENERGAN (promethazine) 12.5MG SUPP,296043,CDM,250,RC,,,Outpatient,,,12.93,7.76,,10.99,85,,8.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.16,32.15,,3.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.35,80.03,,8.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.64,90,,9.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.16,32.15,,3.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.16,32.15,,3.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.38,88,,9.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.28,33.11,,3.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.16,11.64,
SEROQUEL (quetiapine) 100MG TAB,29690,CDM,250,RC,,,Outpatient,,,13,7.8,,11.05,85,,8.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.4,80.03,,8.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.7,90,,9.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,88,,9.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.3,33.11,,3.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.18,11.7,
SALINE NASAL GEL 0.75 OZ,291044,CDM,250,RC,,,Outpatient,,,13,7.8,,11.05,85,,8.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.4,80.03,,8.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.7,90,,9.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,88,,9.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.3,33.11,,3.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.18,11.7,
NEEDLE REGIONAL BLOCK,491669,CDM,270,RC,,,Outpatient,,,13,7.8,,11.05,85,,8.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.4,80.03,,8.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.7,90,,9.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.18,32.15,,3.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,88,,9.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.3,33.11,,3.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.18,11.7,
DEMEROL (meperidine): 25MG/0.5ML AMP,299024,CDM,636,RC,J2175,HCPCS,Outpatient,,,13,7.8,,11.05,85,,8.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.4,80.03,,8.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.7,90,,9.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.44,88,,9.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,11.7,
NIASPAN (niacin ) 1000MG TAB,291080,CDM,250,RC,,,Outpatient,,,13.1,7.86,,11.14,85,,8.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.21,32.15,,3.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.48,80.03,,8.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.79,90,,9.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.21,32.15,,3.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.21,32.15,,3.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.53,88,,9.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.34,33.11,,3.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.21,11.79,
BACITRACIN OINTMENT 30GM,297515,CDM,250,RC,,,Outpatient,,,13.1,7.86,,11.14,85,,8.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.21,32.15,,3.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.48,80.03,,8.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.79,90,,9.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.21,32.15,,3.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.21,32.15,,3.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.53,88,,9.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.34,33.11,,3.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.21,11.79,
VANTIN (cefpodoxime) 200MG TAB,29599,CDM,250,RC,,,Outpatient,,,13.14,7.88,,11.17,85,,8.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.22,32.15,,3.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.52,80.03,,8.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.83,90,,9.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.22,32.15,,3.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.22,32.15,,3.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.56,88,,9.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.35,33.11,,3.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.22,11.83,
NEEDLE 20-15 CHIBA DISP,22262,CDM,270,RC,,,Outpatient,,,13.18,7.91,,11.2,85,,8.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.55,80.03,,8.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.86,90,,9.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,88,,9.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.36,33.11,,3.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.24,11.86,
NEEDLE 22-20 CHIBA DISP,22263,CDM,270,RC,,,Outpatient,,,13.18,7.91,,11.2,85,,8.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.55,80.03,,8.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.86,90,,9.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,88,,9.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.36,33.11,,3.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.24,11.86,
NEEDLE 22-15 CHIBA DISP,22264,CDM,270,RC,,,Outpatient,,,13.18,7.91,,11.2,85,,8.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.55,80.03,,8.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.86,90,,9.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,88,,9.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.36,33.11,,3.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.24,11.86,
NEEDLE 20-20 CHIBA DISP,22265,CDM,270,RC,,,Outpatient,,,13.18,7.91,,11.2,85,,8.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.55,80.03,,8.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.86,90,,9.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,88,,9.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.36,33.11,,3.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.24,11.86,
DETROL LA (tolterodine) 4MG CAP,29764,CDM,250,RC,,,Outpatient,,,13.2,7.92,,11.22,85,,8.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.56,80.03,,8.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.88,90,,9.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.24,32.15,,3.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.62,88,,9.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.37,33.11,,3.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.24,11.88,
SLIDING SCALE HUMAN REG INSULIN,293503,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMAN REG BS-100/ 30,293550,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMAN REG BS-100/ 20,293551,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.25,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMAN REG BS-100/ 25,293552,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMAN REG BS-100/ 40,293553,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMALOG     BS-100/ 30,293554,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMALOG     BS-100/ 20,293555,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMALOG     BS-100/ 25,293556,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE HUMALOG    BS-100/ 40,293557,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE NOVOLOG      BS-100/ 30,293558,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
SLIDING SCALE NOVOLOG      BS-100/ 20,293559,CDM,250,RC,J1815,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,11.93,
AMOXICILLIN 250/5 : 150ML LIQ,294004,CDM,250,RC,,,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.26,32.15,,3.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.26,32.15,,3.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.26,32.15,,3.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.39,33.11,,3.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.26,11.93,
PAVULON (PANCURONIUM) 1MG/ML INJ,296046,CDM,250,RC,,,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.26,32.15,,3.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.26,32.15,,3.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.26,32.15,,3.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.39,33.11,,3.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.26,11.93,
"TRYGLYCERIDES, CDC  (MAYO)",1883707,CDM,300,RC,84478,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,11.93,
"CHOLESTEROL, TOTAL, CDC  (MAYO)",1883708,CDM,300,RC,82465,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.43,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.43,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.47,11.93,
XYLOCAINE (LIDOCAINE) 1% 2ML,293567,CDM,636,RC,J2001,HCPCS,Outpatient,,,13.25,7.95,,11.26,85,,9.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.6,80.03,,8.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.93,90,,9.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.66,88,,9.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,11.93,
MICARDIS (telmisartan) 40MG TAB,29153,CDM,250,RC,,,Outpatient,,,13.3,7.98,,11.31,85,,9.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.28,32.15,,3.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.64,80.03,,8.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,90,,9.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.28,32.15,,3.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.28,32.15,,3.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.7,88,,9.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.4,33.11,,3.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.28,11.97,
FLEET PREP KIT#1,292002,CDM,250,RC,,,Outpatient,,,13.3,7.98,,11.31,85,,9.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.28,32.15,,3.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.64,80.03,,8.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,90,,9.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.28,32.15,,3.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.28,32.15,,3.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.7,88,,9.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.4,33.11,,3.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.28,11.97,
Blood test to screen for syphilis,1884900,CDM,300,RC,86592,HCPCS,Outpatient,,,13.35,8.01,,11.35,85,,9.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.68,80.03,,8.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,12.02,90,,9.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.75,88,,9.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.65,12.02,
CECLOR CD (CEFACLOR) 500MG TAB,29099,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
CEFTIN (CEFUROXIME) 500MG TAB,29811,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.39,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
SODIUM ACETATE : 40MEQ INJ,293159,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.39,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
XYLOCAINE 1GM INJ,293223,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.39,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
ROBINUL (glycopyrrolate) 0.2MG/ML ** 5ML,293563,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
INACTIVE,295049,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
AFRIN NASAL SPRAY : 30ML,297903,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
R & C SPRAY 50Z,298051,CDM,250,RC,,,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.3,32.15,,3.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,33.11,,3.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.3,12.05,
CYANOCOBALAMIN (VIT B-12) 1000MCG INJ,293051,CDM,636,RC,J3420,HCPCS,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.33,12.05,
DECADRON (DEXAMETH) 4MG/ML INJ: 5ML,293053,CDM,636,RC,J1100,HCPCS,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.13,12.05,
PHENERGAN (promethazine) 50MG INJ,293138,CDM,636,RC,J2550,HCPCS,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.48,12.05,
"HEPARIN 20,000 UNITS/ML",293300,CDM,636,RC,J1644,HCPCS,Outpatient,,,13.39,8.03,,11.38,85,,9.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,90,,9.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.78,88,,9.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.28,12.05,
PROTONIX (pantoprazole) 40MG TAB,29374,CDM,250,RC,,,Outpatient,,,13.4,8.04,,11.39,85,,9.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.31,32.15,,3.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.72,80.03,,8.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.06,90,,9.65,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.31,32.15,,3.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.31,32.15,,3.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.79,88,,9.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.44,33.11,,3.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.31,12.06,
OCCULT BLOOD (GASTRIC),1882271,CDM,300,RC,82271,HCPCS,Outpatient,,,13.5,8.1,,11.48,85,,9.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.8,80.03,,8.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,12.15,90,,9.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.88,88,,9.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.04,12.15,
PENICILLAMINE 250 MG TABLET,29613,CDM,250,RC,,,Outpatient,,,13.6,8.16,,11.56,85,,9.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.37,32.15,,3.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.88,80.03,,8.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.24,90,,9.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.37,32.15,,3.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.37,32.15,,3.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.97,88,,9.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.5,33.11,,3.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.37,12.24,
ALBUTEROL INHAL U/D 2.5MG/** 0.5ML CONC,292129,CDM,250,RC,,,Outpatient,,,13.65,8.19,,11.6,85,,9.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.92,80.03,,8.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.29,90,,9.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.01,88,,9.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.52,33.11,,3.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.39,12.29,
DEMADEX (TORSEMIDE) 20MG/2ML INJ,292026,CDM,636,RC,J3265,HCPCS,Outpatient,,,13.65,8.19,,11.6,85,,9.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.92,80.03,,8.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.29,90,,9.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.01,88,,9.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.52,33.11,,3.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.39,12.29,
NEOSPORIN (BACI/NEO/POLYMIX) OPTHOINT UD,2957508,CDM,250,RC,,,Outpatient,,,13.67,8.2,,11.62,85,,9.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10.94,80.03,,8.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.3,90,,9.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.39,32.15,,3.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.03,88,,9.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.53,33.11,,3.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.39,12.3,
CELEBREX (celecoxib) 200MG CAP,29079,CDM,250,RC,,,Outpatient,,,13.75,8.25,,11.69,85,,9.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.42,32.15,,3.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,80.03,,8.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.38,90,,9.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.42,32.15,,3.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.42,32.15,,3.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.1,88,,9.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.55,33.11,,3.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.42,12.38,
CATHETER FOLEY 10FR 3CC LF 2-WAY,49413,CDM,270,RC,,,Outpatient,,,13.75,8.25,,11.69,85,,9.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.42,32.15,,3.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11,80.03,,8.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.38,90,,9.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.42,32.15,,3.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.75,,,,Other,Not Separately reimbursable,4.42,32.15,,3.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.1,88,,9.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.55,33.11,,3.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.42,12.38,
HABITROL (nicotine) 21MG PATCH,292070,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.91,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
COMPAZINE (PROCHLORPERAZINE) SYR : 1OZ,292219,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.91,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
ORGANIDIN (GUAIFENESIN) 100MG/5ML : 1OZ,292252,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.91,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
THORAZINE (CHLORPROMAZ)10MG/5ML:SYR 1OZ,292294,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.91,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
PROGESTERONE INJ 50MG/ML,293022,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
POTASSIUM PHOSPHATE: 22MEQ/5ML,293145,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
TERRAMYCIN 250/2ML INJ,293185,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
XYLOCAINE 2GM INJ,293224,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
MAREZINE INJ : 50MG,293283,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
NEUT- SOD BICARB 4% 5ML VIAL,293447,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
"WYCILLIN 600,000",296065,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
HISTOPLASMIN SKIN TEST,296079,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
TINACTIN 1% CREAM 15GM,297055,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
SILVADENE (SILVER SULFADIAZINE) 25 GM,297076,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
EPPY-N 1/2%OPTH SOL 7.5ML,297707,CDM,250,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
ALPHAKERI BODY LOT.3.75OZ,298030,CDM,270,RC,,,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
RAPID SEQUENCE INTUB. KIT (quel/etom/pav,29933,CDM,636,RC,J0330,HCPCS,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.47,32.15,,3.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.61,33.11,,3.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.47,12.52,
VALIUM (DIAZEAPM ) 10MG/2ML SYRINGE,293056,CDM,636,RC,J3360,HCPCS,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.91,,,,Other,Not Separately reimbursable,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.48,12.52,
INDERAL (PROPRANOLOL) 1MG INJ,293248,CDM,636,RC,J1800,HCPCS,Outpatient,,,13.91,8.35,,11.82,85,,9.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.13,80.03,,8.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.52,90,,10.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,88,,9.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8,12.52,
ARICEPT (donepezil) 5MG TAB,29053,CDM,250,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
TALC POWDER 5GM DOSE,29551,CDM,250,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
LIPITOR (atorvastatin) 40MG TAB,291144,CDM,250,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
FLEETS PHOSPHA-SODA 45ML,292228,CDM,250,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
VYVANSE  (lisdexamphetamine) 30MG TAB,294046,CDM,250,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
VYVANSE  (lisdexamphetamine) 40MG TAB,294107,CDM,250,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
VYVANSE  (lisdexamphetamine) 50MG TAB,294108,CDM,250,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
BENADRYL (diphenhydramine) 50MG/ML INJ,293023,CDM,636,RC,J1200,HCPCS,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,12.6,
ATROPINE 0.4MG/ ML : VIAL,293028,CDM,636,RC,J0461,HCPCS,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,12.6,
HEPARIN 5000 UNITS/ML INJ,293235,CDM,636,RC,J1644,HCPCS,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.28,12.6,
ILOPAN (dexpanthenol) 250 MG/ML 2ML,293573,CDM,636,RC,,,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.5,32.15,,3.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,33.11,,3.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.5,12.6,
XYLOCAINE (lidocaine )  2% INJ 10 ML,293575,CDM,636,RC,J2001,HCPCS,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,12.6,
MORPHINE : 2MG INJ,299075,CDM,636,RC,J2270,HCPCS,Outpatient,,,14,8.4,,11.9,85,,9.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.2,80.03,,8.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.6,90,,10.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.32,88,,9.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,12.6,
REGLAN (metoclopramide) 10MG/2ML INJ,293155,CDM,636,RC,J2765,HCPCS,Outpatient,,,14.03,8.42,,11.93,85,,9.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.23,80.03,,8.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.63,90,,10.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.35,88,,9.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.11,12.63,
RESTORIL (TEMAZEPAM) 7.5MG CAP,291075,CDM,250,RC,,,Outpatient,,,14.1,8.46,,11.99,85,,9.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.53,32.15,,3.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.28,80.03,,9.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.69,90,,10.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.53,32.15,,3.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.53,32.15,,3.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.41,88,,9.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.67,33.11,,3.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.53,12.69,
POTASS CHLOR 20MEQ/15ML SOLN : UD,292327,CDM,250,RC,,,Outpatient,,,14.2,8.52,,12.07,85,,9.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.57,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.36,80.03,,9.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.78,90,,10.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.57,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.57,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.5,88,,10,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.7,33.11,,3.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.57,12.78,
AMINOPHYLLINE: 250MG/10ML INJ,293008,CDM,636,RC,J0280,HCPCS,Outpatient,,,14.2,8.52,,12.07,85,,9.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.36,80.03,,9.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.78,90,,10.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.2,,,,Other,Not Separately reimbursable,10.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.5,88,,10,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.59,12.78,
ALBUTEROL INHAL U/D 2.5MG/** 3ML,292060,CDM,250,RC,,,Outpatient,,,14.25,8.55,,12.11,85,,9.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.4,80.03,,9.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.83,90,,10.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.25,,,,Other,Not Separately reimbursable,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.54,88,,10.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.72,33.11,,3.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.58,12.83,
CATHETER FOLEY 18FR 30CC 3-WAY,49414,CDM,270,RC,,,Outpatient,,,14.25,8.55,,12.11,85,,9.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.4,80.03,,9.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.83,90,,10.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.25,,,,Other,Not Separately reimbursable,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.54,88,,10.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.72,33.11,,3.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.58,12.83,
DIAPER LITTLE SNUGGLERS SIZE 1 HUGGIES,490872,CDM,270,RC,,,Outpatient,,,14.25,8.55,,12.11,85,,9.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.4,80.03,,9.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.83,90,,10.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.58,32.15,,3.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.54,88,,10.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.72,33.11,,3.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.58,12.83,
PREVACID (lansoprazole) 30MG (NG TUBE),29692,CDM,250,RC,,,Outpatient,,,14.33,8.6,,12.18,85,,9.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.47,80.03,,9.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.9,90,,10.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.61,88,,10.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.74,33.11,,3.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.61,12.9,
LIALDA  (mesalamine) DR 1.2 GM  TAB,291123,CDM,250,RC,,,Outpatient,,,14.33,8.6,,12.18,85,,9.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.47,80.03,,9.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.9,90,,10.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.61,88,,10.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.74,33.11,,3.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.61,12.9,
TOPAMAX (topiramate) 200 MG TABLET,291174,CDM,250,RC,,,Outpatient,,,14.35,8.61,,12.2,85,,9.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.48,80.03,,9.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.92,90,,10.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.61,32.15,,3.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.63,88,,10.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,33.11,,3.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.61,12.92,
AUGMENTIN (amox/clav acid) 875MG TAB,29763,CDM,250,RC,,,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.77,33.11,,3.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.64,12.98,
EMETE CON INJ : 50MG VIAL,293077,CDM,250,RC,,,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.77,33.11,,3.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.64,12.98,
HUMALOG INSULIN U-100 INJ,293407,CDM,250,RC,J1815,HCPCS,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,12.98,
HALOG 0.1% CREAM 15GM,297020,CDM,250,RC,,,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.77,33.11,,3.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.64,12.98,
LOTRIMIN SOLN (CLOTRIMAZOLE) 1% 30ML,297029,CDM,250,RC,,,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.77,33.11,,3.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.64,12.98,
TEARISOL (ART.TEARS) OPTH OINT,297739,CDM,250,RC,,,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.77,33.11,,3.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.64,12.98,
OTRIVIN NASAL DROPS : 20ML,297910,CDM,250,RC,,,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.64,32.15,,3.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.77,33.11,,3.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.64,12.98,
VISTARIL (hyDROXYzine): 50MG/ML INJ,293211,CDM,636,RC,J3410,HCPCS,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.54,13.15,
XYLOC 2% (LIDOCAINE): MDV 50ML,293218,CDM,636,RC,J2001,HCPCS,Outpatient,,,14.42,8.65,,12.26,85,,9.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.54,80.03,,9.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.98,90,,10.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.69,88,,10.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,12.98,
HUMALOG INS MIX 75/25 INJ,293459,CDM,250,RC,J1815,HCPCS,Outpatient,,,14.45,8.67,,12.28,85,,9.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.56,80.03,,9.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,90,,10.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.72,88,,10.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,13.01,
HUMALOG INS MIX 50/50 INJ,293537,CDM,250,RC,J1815,HCPCS,Outpatient,,,14.45,8.67,,12.28,85,,9.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.56,80.03,,9.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,90,,10.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.72,88,,10.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,13.01,
AUGMENTIN XR (AMOX/CLAV) 1000MG TAB,29878,CDM,250,RC,,,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.5,,,,Other,Not Separately reimbursable,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.8,33.11,,3.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.66,13.05,
LYRICA (pregabalin) 75MG CAP,291054,CDM,250,RC,,,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.8,33.11,,3.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.66,13.05,
BUMEX (bumetanide) 0.25MG/ML *10ML,293362,CDM,250,RC,S0171,HCPCS,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.8,33.11,,3.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.66,13.05,
"NILSTAT (mycostat) 100,000U/ML Susp: 1OZ",294024,CDM,250,RC,,,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.8,33.11,,3.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.66,13.05,
CAPSAICIN 0.025% CREAM,297097,CDM,250,RC,,,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.66,32.15,,3.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.8,33.11,,3.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.66,13.05,
HEMATOCRIT (HCT),1885014,CDM,300,RC,85014,HCPCS,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2.41,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2.41,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.98,13.05,
Blood test to measure levels of hemoglobin,1885018,CDM,300,RC,85018,HCPCS,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2.41,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2.41,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.98,13.05,
LIDOCAINE 1.5% WITH EPI 1:200 5ML AMP,293603,CDM,636,RC,J2001,HCPCS,Outpatient,,,14.5,8.7,,12.33,85,,9.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.6,80.03,,9.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.05,90,,10.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.76,88,,10.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,13.05,
PLAVIX (clopidogrel) 75MG TAB,29844,CDM,250,RC,,,Outpatient,,,14.8,8.88,,12.58,85,,10.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.76,32.15,,3.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.84,80.03,,9.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.32,90,,10.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.76,32.15,,3.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.76,32.15,,3.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.02,88,,10.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.9,33.11,,3.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.76,13.32,
URECHOLINE (BETHANECHOL) 5MG/ML INJ,293201,CDM,250,RC,,,Outpatient,,,14.94,8.96,,12.7,85,,10.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.96,80.03,,9.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.45,90,,10.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.15,88,,10.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.95,33.11,,3.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.8,13.45,
POLYCOSE POWDER 1LB,295682,CDM,250,RC,,,Outpatient,,,14.94,8.96,,12.7,85,,10.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.96,80.03,,9.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.45,90,,10.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.15,88,,10.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.95,33.11,,3.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.8,13.45,
CORTISPORIN OINT 15GM,297013,CDM,250,RC,,,Outpatient,,,14.94,8.96,,12.7,85,,10.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.96,80.03,,9.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.45,90,,10.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.15,88,,10.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.95,33.11,,3.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.8,13.45,
ZOVIRAX (acyclovir) 200MG/5ML SUSP: 1OZ,298061,CDM,250,RC,,,Outpatient,,,14.94,8.96,,12.7,85,,10.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.96,80.03,,9.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.45,90,,10.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.8,32.15,,3.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.15,88,,10.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.95,33.11,,3.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.8,13.45,
VERSED (midazolam): 2MG/2ML VIAL,293209,CDM,636,RC,J2250,HCPCS,Outpatient,,,14.94,8.96,,12.7,85,,10.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.96,80.03,,9.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.45,90,,10.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.15,88,,10.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.17,13.45,
DRESSING TRANSPARENT 2X3  STERILE,49115,CDM,270,RC,,,Outpatient,,,14.97,8.98,,12.72,85,,10.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.81,32.15,,3.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.98,80.03,,9.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.47,90,,10.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.81,32.15,,3.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.81,32.15,,3.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.17,88,,10.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.96,33.11,,3.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.81,13.47,
NORCURON (VECURONIUM) 10MG INJ,293401,CDM,250,RC,,,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
PAVULON (PANCURONIUM) 1MG/ML 10ML VIAL,296092,CDM,250,RC,,,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
ADULT MASK,30195,CDM,270,RC,94799,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
TEMP SENSOR,30335,CDM,270,RC,,,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15,,,,Other,Not Separately reimbursable,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
SCD MAINTENANCE/CHECK,31102,CDM,270,RC,,,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
Quantitative measure of glucose build up in the blood over time,18001,CDM,300,RC,82947,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,13.5,
"OSMOLALITY, 24HR URINE  (MAYO)",1882204,CDM,300,RC,83935,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.57,13.5,
PKU,1884030,CDM,300,RC,84030,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.92,13.5,
Use of external hot or cold packs,313013,CDM,430,RC,97010,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",313015,CDM,430,RC,97016,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.44,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
PARAFFIN BATH,313016,CDM,430,RC,97018,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.47,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.47,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,4.82,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.97,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.82,13.5,
ATROPINE 0.1MG/ 1 ML COMPOUND (ORAL),293001,CDM,636,RC,J0461,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,13.5,
VERSED (midazolam): 5MG/ML INJ,293334,CDM,636,RC,J2250,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.17,13.5,
VERSED (midazolam) 50MG/ 10ML VIAL,293842,CDM,636,RC,J2250,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.17,13.5,
HABITROL (nicotine ) 14MG PATCH,292074,CDM,250,RC,,,Outpatient,,,15.03,9.02,,12.78,85,,10.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.83,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.03,80.03,,9.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.53,90,,10.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.83,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.83,32.15,,3.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.23,88,,10.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.98,33.11,,3.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.83,13.53,
SKELAXIN (metaxalone) 800MG TAB,29246,CDM,250,RC,,,Outpatient,,,15.1,9.06,,12.84,85,,10.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.85,32.15,,3.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.08,80.03,,9.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.59,90,,10.87,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.85,32.15,,3.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.85,32.15,,3.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.29,88,,10.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5,33.11,,4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.85,13.59,
RENAGEL (SEVELAMER) 800MG TAB,29577,CDM,250,RC,,,Outpatient,,,15.3,9.18,,13.01,85,,10.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,80.03,,9.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,90,,11.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.46,88,,10.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.07,33.11,,4.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.92,13.77,
TRICOR (fenofibrate) 145 MG TAB,291007,CDM,250,RC,,,Outpatient,,,15.3,9.18,,13.01,85,,10.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,80.03,,9.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,90,,11.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.46,88,,10.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.07,33.11,,4.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.92,13.77,
ROBINUL (glycopyrrolate) 0.2MG/ML INJ,293157,CDM,250,RC,,,Outpatient,,,15.3,9.18,,13.01,85,,10.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,80.03,,9.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,90,,11.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.46,88,,10.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.07,33.11,,4.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.92,13.77,
LANSINOH (lanolin) CREAM  40 GM TUBE,298063,CDM,250,RC,,,Outpatient,,,15.3,9.18,,13.01,85,,10.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.24,80.03,,9.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,90,,11.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.92,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.46,88,,10.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.07,33.11,,4.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.92,13.77,
AUGMENTIN (amox/clav) 400MG/5ML :5ML-U/D,294101,CDM,250,RC,,,Outpatient,,,15.33,9.2,,13.03,85,,10.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.27,80.03,,9.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.8,90,,11.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.49,88,,10.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,33.11,,4.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.93,13.8,
AUGMENTIN (amox/clav) 200MG/5ML :5ML-U/D,294110,CDM,250,RC,,,Outpatient,,,15.33,9.2,,13.03,85,,10.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.27,80.03,,9.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.8,90,,11.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.33,,,,Other,Not Separately reimbursable,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.49,88,,10.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,33.11,,4.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.93,13.8,
OXANDROLONE 2.5MG TABLET,295512,CDM,250,RC,,,Outpatient,,,15.33,9.2,,13.03,85,,10.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.27,80.03,,9.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.8,90,,11.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.93,32.15,,3.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.49,88,,10.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,33.11,,4.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.93,13.8,
MAG SULFATE: 1GM/2ML VIAL,293102,CDM,636,RC,J3475,HCPCS,Outpatient,,,15.35,9.21,,13.05,85,,10.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.28,80.03,,9.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.82,90,,11.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,88,,10.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.76,13.82,
"POTASSIUM, BLOOD",1884132,CDM,300,RC,84132,HCPCS,Outpatient,,,15.38,9.23,,13.07,85,,10.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.31,80.03,,9.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.84,90,,11.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.53,88,,10.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.78,13.84,
"SODIUM, BLOOD",1884295,CDM,300,RC,84295,HCPCS,Outpatient,,,15.38,9.23,,13.07,85,,10.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.31,80.03,,9.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.84,90,,11.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.53,88,,10.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.05,13.84,
CHLOROMYCETIN (CHLORAMPHEN) 1GM VIAL,293038,CDM,636,RC,J0720,HCPCS,Outpatient,,,15.45,9.27,,13.13,85,,10.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.36,80.03,,9.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.91,90,,11.13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,48.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.6,88,,10.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.36,48.65,
MAGNESIUM SULF 50%:20ML,293327,CDM,636,RC,J3475,HCPCS,Outpatient,,,15.45,9.27,,13.13,85,,10.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.36,80.03,,9.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.91,90,,11.13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.6,88,,10.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.76,13.91,
CRESTOR (rosuvastatin)10MG TAB,29442,CDM,250,RC,,,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.13,33.11,,4.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.98,13.95,
ZETIA (ezetimibe) 10MG TAB,29681,CDM,250,RC,,,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.13,33.11,,4.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.98,13.95,
DEXTROSE 10% 5ML AMPS,293289,CDM,250,RC,,,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,4.98,32.15,,3.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.13,33.11,,4.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4.98,13.95,
ALTERNARIA TENUIS IGE (MAYO),1884830,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
ASPERGILLUS FUMIGATUS IGE (MAYO),1884831,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
CAT EPITHELIUM IGE (MAYO),1884832,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
CLADOSPORIUM IGE (MAYO),1884833,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
HOUSE DUST MITES D.F. IGE (MAYO),1884834,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
DOG DANDER IGE (MAYO),1884835,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
HOUSE DUST MITES D.P. IGE (MAYO),1884836,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
HOUSE DUST GREER LAB IGE (MAYO),1884837,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
HOUSE DUST H S LAB IGE (MAYO),1884838,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
PENICILLIUM IGE (MAYO),1884839,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
SILVER BIRCH IGE SILVER BIRCH IGE (MAYO),1884841,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"BOX ELD/MAPLE, S IGE (MAYO)",1884842,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
ENGLISH PLANTAIN IGE (MAYO),1884843,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
ELM IGE (MAYO),1884844,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
JUNE GRASS IGE (MAYO),1884845,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
LAMBS QUARTER IGE (MAYO),1884846,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
OAK IGE (MAYO),1884847,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
RYE GRASS (MAYO),1884848,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
SHORT RAGWEED IGE (MAYO),1884849,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
TIMOTHY GRASS IGE (MAYO),1884850,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"MOUNTAIN CEDAR, IGE (MAYO)",1884862,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"COCKROACH, IGE (MAYO)",1884863,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"BAHIA GRASS, IGE (MAYO)",1884864,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"ROUGH PIGWEED, IGE (MAYO)",1884865,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"NETTLE, IGE (MAYO)",1884866,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"RED SORREL, IGE (MAYO)",1884867,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"BERMUDA GRASS, IGE (MAYO)",1884868,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
"PECAN HICKORY, IGE (MAYO)",1884869,CDM,300,RC,86003,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,13.95,
MAG SULFATE 4G/100ML SW**,293883,CDM,636,RC,J3475,HCPCS,Outpatient,,,15.5,9.3,,13.18,85,,10.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.4,80.03,,9.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.95,90,,11.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.64,88,,10.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.76,13.95,
"Complete blood cell count, with differential white blood cells, automated",1884820,CDM,300,RC,85025,HCPCS,Outpatient,,,15.54,9.32,,13.21,85,,10.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.44,80.03,,9.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.92,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,13.99,90,,11.19,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.92,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.68,88,,10.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.77,13.99,
SLIDING SCALE-HUMALOG INS,293505,CDM,250,RC,J1815,HCPCS,Outpatient,,,15.55,9.33,,13.22,85,,10.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.44,80.03,,9.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14,90,,11.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.68,88,,10.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,14,
SLIDING SCALE-NOVOLOG INSULIN,293821,CDM,250,RC,J1815,HCPCS,Outpatient,,,15.55,9.33,,13.22,85,,10.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.44,80.03,,9.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14,90,,11.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.68,88,,10.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,14,
PENTASA (mesalamine) 500 MG CR CAP,291161,CDM,250,RC,,,Outpatient,,,15.6,9.36,,13.26,85,,10.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.02,32.15,,4.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.48,80.03,,9.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.04,90,,11.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.02,32.15,,4.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.02,32.15,,4.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.73,88,,10.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.17,33.11,,4.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.02,14.04,
BASIN WASH 6 QT.,490001,CDM,270,RC,,,Outpatient,,,15.79,9.47,,13.42,85,,10.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.08,32.15,,4.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.64,80.03,,10.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.21,90,,11.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.08,32.15,,4.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.08,32.15,,4.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.9,88,,11.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.23,33.11,,4.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.08,14.21,
FLUSH- 30ML VIAL BACTERIOSTATIC NACL,293112,CDM,272,RC,A4218,HCPCS,Outpatient,,,15.84,9.5,,13.46,85,,10.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.09,32.15,,4.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.68,80.03,,10.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.26,90,,11.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.09,32.15,,4.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.09,32.15,,4.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.94,88,,11.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.24,33.11,,4.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.09,14.26,
LANOXIN (digoxin) 0.5MG/2ML AMP,293093,CDM,636,RC,J1160,HCPCS,Outpatient,,,15.84,9.5,,13.46,85,,10.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.68,80.03,,10.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.26,90,,11.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,11.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.94,88,,11.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.36,14.26,
ALIMENTUM ADVANCED : 32OZ,292313,CDM,250,RC,,,Outpatient,,,15.97,9.58,,13.57,85,,10.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.78,80.03,,10.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.37,90,,11.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.05,88,,11.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.29,33.11,,4.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.13,14.37,
DELALUTIN 250MG/ML INJ : 1ML,293059,CDM,250,RC,,,Outpatient,,,15.97,9.58,,13.57,85,,10.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.78,80.03,,10.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.37,90,,11.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.05,88,,11.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.29,33.11,,4.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.13,14.37,
AVEENO COLLOIDAL OATMEAL,295505,CDM,250,RC,,,Outpatient,,,15.97,9.58,,13.57,85,,10.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.78,80.03,,10.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.37,90,,11.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.05,88,,11.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.29,33.11,,4.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.13,14.37,
SCOPOLAMINE 0.4MG/ML INJ,296074,CDM,250,RC,,,Outpatient,,,15.97,9.58,,13.57,85,,10.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.78,80.03,,10.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.37,90,,11.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.05,88,,11.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.29,33.11,,4.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.13,14.37,
VIT E OIL 10Z,298057,CDM,250,RC,,,Outpatient,,,15.97,9.58,,13.57,85,,10.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.78,80.03,,10.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.37,90,,11.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.13,32.15,,4.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.05,88,,11.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.29,33.11,,4.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.13,14.37,
COMPAZINE (PROCHLORPERAZINE) 10MG/2ML IN,293045,CDM,636,RC,J0780,HCPCS,Outpatient,,,15.97,9.58,,13.57,85,,10.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.78,80.03,,10.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.37,90,,11.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.05,88,,11.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.85,14.37,
SOLU CORTEF (hydrocortisone) 250MG INJ,293167,CDM,636,RC,J1720,HCPCS,Outpatient,,,15.97,9.58,,13.57,85,,10.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.78,80.03,,10.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.37,90,,11.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.05,88,,11.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.78,17.67,
CEFTIN (CEFUROXIME) 250MG/5ML : DOSE,29915,CDM,250,RC,,,Outpatient,,,16,9.6,,13.6,85,,10.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.8,80.03,,10.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.4,90,,11.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.08,88,,11.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.3,33.11,,4.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.14,14.4,
TYLENOL (acetaminophen)  DROPS,294034,CDM,250,RC,,,Outpatient,,,16,9.6,,13.6,85,,10.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.8,80.03,,10.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.4,90,,11.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16,,,,Other,Not Separately reimbursable,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.08,88,,11.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.3,33.11,,4.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.14,14.4,
AQUAPHOR OINTMENT 3 OZ,297106,CDM,250,RC,,,Outpatient,,,16,9.6,,13.6,85,,10.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.8,80.03,,10.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.4,90,,11.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16,,,,Other,Not Separately reimbursable,5.14,32.15,,4.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.08,88,,11.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.3,33.11,,4.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.14,14.4,
HEPARIN 1000 UNITS/ML 1ML,293315,CDM,636,RC,J1644,HCPCS,Outpatient,,,16,9.6,,13.6,85,,10.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.8,80.03,,10.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.4,90,,11.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16,,,,Other,Not Separately reimbursable,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.08,88,,11.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.28,14.4,
HYCODAN SYRUP : 1OZ,292238,CDM,250,RC,,,Outpatient,,,16.1,9.66,,13.69,85,,10.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.18,32.15,,4.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.88,80.03,,10.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.49,90,,11.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.18,32.15,,4.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.18,32.15,,4.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,88,,11.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.33,33.11,,4.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.18,14.49,
MS-CONTIN (MORPHINE) 60MG TAB,29333,CDM,250,RC,,,Outpatient,,,16.2,9.72,,13.77,85,,11.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.21,32.15,,4.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.96,80.03,,10.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.58,90,,11.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.21,32.15,,4.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.21,32.15,,4.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.26,88,,11.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.36,33.11,,4.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.21,14.58,
EXELON (rivastigmine) 9.5MG/24HR PATCH,291169,CDM,250,RC,,,Outpatient,,,16.2,9.72,,13.77,85,,11.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.21,32.15,,4.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12.96,80.03,,10.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.58,90,,11.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.21,32.15,,4.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.21,32.15,,4.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.26,88,,11.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.36,33.11,,4.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.21,14.58,
VALTREX (valacyclovir) 500 MG TAB,291056,CDM,250,RC,,,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.38,33.11,,4.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.22,14.63,
TALWIN 30MG/ML INJ,293182,CDM,250,RC,J3070,HCPCS,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.38,33.11,,4.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.22,14.63,
PLUG DECANNULATION SIZE 1 DISPOSABLE,49670,CDM,270,RC,,,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.38,33.11,,4.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.22,14.63,
DRESSING TENDERWET 1.6  ROUND PREWET,498032,CDM,272,RC,,,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.38,33.11,,4.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.22,14.63,
DOPPLER ECHO COLOR FLOW INTERPRETATION,3013,CDM,480,RC,93325,HCPCS,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.38,33.11,,4.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.22,14.63,
DOPPLER ECHO COLOR FLOW INTERPRETATION,4020,CDM,480,RC,93325,HCPCS,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.38,33.11,,4.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.22,14.63,
DOPPLER ECHO FLOW INTREPRE STEP DOWN/ICU,15013,CDM,480,RC,93325,HCPCS,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.22,32.15,,4.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.38,33.11,,4.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.22,14.63,
LASIX (furosemide): 40MG/4ML INJ,293096,CDM,636,RC,J1940,HCPCS,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.58,14.63,
POTASSIUM ACETATE: 2 MEQ/ ML 20ML VIAL,293580,CDM,636,RC,J3480,HCPCS,Outpatient,,,16.25,9.75,,13.81,85,,11.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13,80.03,,10.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,11.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.3,88,,11.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.11,14.63,
BUMEX (bumetanide) 1 MG / 4ML INJ,293312,CDM,250,RC,S0171,HCPCS,Outpatient,,,16.3,9.78,,13.86,85,,11.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.24,32.15,,4.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.04,80.03,,10.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.67,90,,11.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.24,32.15,,4.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.24,32.15,,4.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.34,88,,11.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.4,33.11,,4.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.24,14.67,
DERMOPLAST SPRAY,295695,CDM,250,RC,,,Outpatient,,,16.33,9.8,,13.88,85,,11.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.25,32.15,,4.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.07,80.03,,10.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.7,90,,11.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.25,32.15,,4.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.25,32.15,,4.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.37,88,,11.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.41,33.11,,4.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.25,14.7,
LEVALL (carbet/pheneph/guai) LIQ : 1OZ,292331,CDM,250,RC,,,Outpatient,,,16.48,9.89,,14.01,85,,11.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.19,80.03,,10.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.83,90,,11.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.5,88,,11.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.46,33.11,,4.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.3,14.83,
OTRIVIN PEDI NASAL DROPS: 20ML,297911,CDM,250,RC,,,Outpatient,,,16.48,9.89,,14.01,85,,11.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.19,80.03,,10.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.83,90,,11.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.48,,,,Other,Not Separately reimbursable,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.5,88,,11.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.46,33.11,,4.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.3,14.83,
DILANTIN (phenytoin) 250MG AMP,293070,CDM,636,RC,J1165,HCPCS,Outpatient,,,16.48,9.89,,14.01,85,,11.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.19,80.03,,10.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.83,90,,11.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.48,,,,Other,Not Separately reimbursable,0.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.5,88,,11.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.46,14.83,
OMNIPAQUE 9/ML 500ML VIAL,300899,CDM,250,RC,Q9967,HCPCS,Outpatient,,,16.5,9.9,,14.03,85,,11.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,80.03,,10.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.85,90,,11.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.5,,,,Other,Not Separately reimbursable,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.52,88,,11.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.46,33.11,,4.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.3,14.85,
SOD CHLORIDE 4MEQ/ML: 30ML,293319,CDM,258,RC,J7131,HCPCS,Outpatient,,,16.5,9.9,,14.03,85,,11.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.2,80.03,,10.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.85,90,,11.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.5,,,,Other,Not Separately reimbursable,5.3,32.15,,4.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.52,88,,11.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.46,33.11,,4.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.3,14.85,
"EGG WHITE, IGE (MAYO)",1882101,CDM,300,RC,86003,HCPCS,Outpatient,,,16.5,9.9,,14.03,85,,11.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,80.03,,10.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,14.85,90,,11.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.52,88,,11.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,14.85,
"MILK, IGE (MAYO)",1882102,CDM,300,RC,86003,HCPCS,Outpatient,,,16.5,9.9,,14.03,85,,11.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,80.03,,10.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,14.85,90,,11.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.52,88,,11.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,14.85,
"OAT, IGE (MAYO)",1882103,CDM,300,RC,86003,HCPCS,Outpatient,,,16.5,9.9,,14.03,85,,11.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,80.03,,10.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,14.85,90,,11.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.52,88,,11.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,14.85,
"SOYBEAN, IGE (MAYO)",1882106,CDM,300,RC,86003,HCPCS,Outpatient,,,16.5,9.9,,14.03,85,,11.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,80.03,,10.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,14.85,90,,11.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.52,88,,11.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,14.85,
"WHEAT, IGE (MAYO)",1882107,CDM,300,RC,86003,HCPCS,Outpatient,,,16.5,9.9,,14.03,85,,11.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,80.03,,10.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,14.85,90,,11.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.52,88,,11.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,14.85,
BANDAGE GAUZE 3 X75  STRETCH STERILE,49135,CDM,270,RC,,,Outpatient,,,16.61,9.97,,14.12,85,,11.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.34,32.15,,4.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.29,80.03,,10.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.95,90,,11.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.34,32.15,,4.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.34,32.15,,4.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.62,88,,11.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.5,33.11,,4.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.34,14.95,
FORTAZ (CEFTAZIDIME) 250MG DIALYSIS,293427,CDM,636,RC,J0713,HCPCS,Outpatient,,,16.79,10.07,,14.27,85,,11.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.44,80.03,,10.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.11,90,,12.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.78,88,,11.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.78,15.11,
LIPITOR (atorvastatin) 20MG TAB,29363,CDM,250,RC,,,Outpatient,,,16.8,10.08,,14.28,85,,11.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.45,80.03,,10.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.12,90,,12.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.78,88,,11.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.56,33.11,,4.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.4,15.12,
CYMBALTA (duloxetine) 60MG CAP,291132,CDM,250,RC,,,Outpatient,,,16.8,10.08,,14.28,85,,11.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.45,80.03,,10.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.12,90,,12.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.78,88,,11.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.56,33.11,,4.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.4,15.12,
REGONOL (PYRIDOSTIGMINE) 10MG/2ML INJ,293299,CDM,250,RC,,,Outpatient,,,16.8,10.08,,14.28,85,,11.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.45,80.03,,10.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.12,90,,12.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.78,88,,11.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.56,33.11,,4.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.4,15.12,
ACTOS (pioglitazone) 15MG,29718,CDM,250,RC,,,Outpatient,,,16.81,10.09,,14.29,85,,11.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.45,80.03,,10.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.13,90,,12.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.4,32.15,,4.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.79,88,,11.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.57,33.11,,4.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.4,15.13,
LIPITOR (atorvastatin) 80MG TAB,29428,CDM,250,RC,,,Outpatient,,,17,10.2,,14.45,85,,11.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.61,80.03,,10.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,90,,12.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.96,88,,11.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.63,33.11,,4.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.47,15.3,
SODIUM BICARB : 0.5MEQ BUFFER,293194,CDM,250,RC,,,Outpatient,,,17,10.2,,14.45,85,,11.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.61,80.03,,10.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,90,,12.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.96,88,,11.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.63,33.11,,4.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.47,15.3,
DIAPER NEWBORN 1-10 LB,490870,CDM,270,RC,,,Outpatient,,,17,10.2,,14.45,85,,11.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.61,80.03,,10.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,90,,12.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.96,88,,11.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.63,33.11,,4.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.47,15.3,
BETA 2 MICROGLOBULIN  (MAYO),1882689,CDM,300,RC,82232,HCPCS,Outpatient,,,17,10.2,,14.45,85,,11.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.61,80.03,,10.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.3,90,,12.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.96,88,,11.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.61,20.35,
NEO SYNEPHRINE (phenylephrin) 1% AMP 1ML,293117,CDM,636,RC,J2370,HCPCS,Outpatient,,,17,10.2,,14.45,85,,11.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.61,80.03,,10.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,90,,12.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.47,32.15,,4.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.96,88,,11.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.63,33.11,,4.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.47,15.3,
ADRENALIN (epinephrine) 1: 1000 1MG,293002,CDM,636,RC,J0171,HCPCS,Outpatient,,,17.15,10.29,,14.58,85,,11.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.73,80.03,,10.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.44,90,,12.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.09,88,,12.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.78,15.44,
ROBAXIN (methocarbamol)100MG/ML:INJ 10ML,293251,CDM,250,RC,,,Outpatient,,,17.25,10.35,,14.66,85,,11.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.18,88,,12.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.71,33.11,,4.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.55,15.53,
HONEY BEE ALLERGAN  (MAYO),1886041,CDM,300,RC,86003,HCPCS,Outpatient,,,17.25,10.35,,14.66,85,,11.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.18,88,,12.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,15.53,
WHITE FACED HORNET ALLERGAN  (MAYO),1886042,CDM,300,RC,86003,HCPCS,Outpatient,,,17.25,10.35,,14.66,85,,11.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.18,88,,12.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,15.53,
YELLOW HORNET ALLERGAN  (MAYO),1886043,CDM,300,RC,86003,HCPCS,Outpatient,,,17.25,10.35,,14.66,85,,11.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.18,88,,12.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,15.53,
WASP ALLERGAN  (MAYO),1886044,CDM,300,RC,86003,HCPCS,Outpatient,,,17.25,10.35,,14.66,85,,11.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.18,88,,12.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,15.53,
YELLOW JACKET ALLERGAN  (MAYO),1886045,CDM,300,RC,86003,HCPCS,Outpatient,,,17.25,10.35,,14.66,85,,11.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.18,88,,12.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,15.53,
LTA (4%LIDOCAINE)INTUBATION KIT 4ML,293494,CDM,636,RC,J2001,HCPCS,Outpatient,,,17.25,10.35,,14.66,85,,11.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.18,88,,12.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,15.53,
LOMOTIL (dephenoxylate/atropine) LIQ 1OZ,292242,CDM,250,RC,,,Outpatient,,,17.26,10.36,,14.67,85,,11.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.19,88,,12.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.71,33.11,,4.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.55,15.53,
LACTOFREE RTU : 32OZ CAN,292318,CDM,250,RC,,,Outpatient,,,17.26,10.36,,14.67,85,,11.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.19,88,,12.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.71,33.11,,4.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.55,15.53,
DILANTIN RM SYRINGE : 250MG,293069,CDM,250,RC,,,Outpatient,,,17.26,10.36,,14.67,85,,11.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.19,88,,12.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.71,33.11,,4.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.55,15.53,
NEODECADRON OPTH 3.5GM,297507,CDM,250,RC,,,Outpatient,,,17.26,10.36,,14.67,85,,11.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.19,88,,12.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.71,33.11,,4.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.55,15.53,
ISOPTO CARPINE1/2% O/S,297714,CDM,250,RC,,,Outpatient,,,17.26,10.36,,14.67,85,,11.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.55,32.15,,4.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.19,88,,12.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.71,33.11,,4.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.55,15.53,
DILANTIN (phenytoin) 100MG/2ML INJ,293068,CDM,636,RC,J1165,HCPCS,Outpatient,,,17.26,10.36,,14.67,85,,11.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.19,88,,12.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.46,15.53,
NARCAN (NEONATAL) (NALOXONE) 0.02MG/ML,293121,CDM,636,RC,J2310,HCPCS,Outpatient,,,17.26,10.36,,14.67,85,,11.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,80.03,,11.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.53,90,,12.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.19,88,,12.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.54,15.53,
VFEND (voriconazole) 50mg  TAB,29156,CDM,250,RC,J3465,HCPCS,Outpatient,,,17.3,10.38,,14.71,85,,11.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.56,32.15,,4.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.85,80.03,,11.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.57,90,,12.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.56,32.15,,4.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.56,32.15,,4.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.22,88,,12.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.73,33.11,,4.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.56,15.57,
TAMIFLU (oseltamivir) 30 MG CAP,29916,CDM,250,RC,,,Outpatient,,,17.3,10.38,,14.71,85,,11.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.56,32.15,,4.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.85,80.03,,11.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.57,90,,12.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.56,32.15,,4.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.3,,,,Other,Not Separately reimbursable,5.56,32.15,,4.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.22,88,,12.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.73,33.11,,4.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.56,15.57,
DUONEB (albut2.5/ipratrop0.5) INHAL 3ML,292144,CDM,250,RC,,,Outpatient,,,17.33,10.4,,14.73,85,,11.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.57,32.15,,4.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.87,80.03,,11.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.6,90,,12.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.57,32.15,,4.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.57,32.15,,4.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.25,88,,12.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.74,33.11,,4.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.57,15.6,
EFFEXOR XR (venlafaxine) 150MG CAP,29231,CDM,250,RC,,,Outpatient,,,17.35,10.41,,14.75,85,,11.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.58,32.15,,4.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.89,80.03,,11.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.62,90,,12.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.58,32.15,,4.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.58,32.15,,4.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.27,88,,12.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.74,33.11,,4.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.58,15.62,
ZYRTEC (cetirizine) 1MG/ML SYRUP: 1OZ,292330,CDM,250,RC,,,Outpatient,,,17.5,10.5,,14.88,85,,11.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.01,80.03,,11.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,90,,12.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.4,88,,12.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.79,33.11,,4.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.63,15.75,
PHENERGAN (promethazine) 25MG SUPP,296044,CDM,250,RC,,,Outpatient,,,17.5,10.5,,14.88,85,,11.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.01,80.03,,11.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,90,,12.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.4,88,,12.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.79,33.11,,4.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.63,15.75,
NEOSPORIN GU  IRRIGANT 20ML MDV,301906,CDM,250,RC,,,Outpatient,,,17.5,10.5,,14.88,85,,11.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.01,80.03,,11.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,90,,12.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.4,88,,12.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.79,33.11,,4.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.63,15.75,
DRESSING TENDERWET 2.2  CAVITY RD PREWET,498030,CDM,272,RC,,,Outpatient,,,17.5,10.5,,14.88,85,,11.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.01,80.03,,11.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,90,,12.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.63,32.15,,4.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.4,88,,12.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.79,33.11,,4.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.63,15.75,
MARINOL (DRONABINOL) 5MG CAP,29704,CDM,250,RC,,,Outpatient,,,17.72,10.63,,15.06,85,,12.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.7,32.15,,4.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.18,80.03,,11.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.95,90,,12.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.7,32.15,,4.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.7,32.15,,4.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.59,88,,12.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.87,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.7,15.95,
MARINOL (DRONABINOL)2.5 CAP,29739,CDM,250,RC,,,Outpatient,,,17.72,10.63,,15.06,85,,12.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.7,32.15,,4.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.18,80.03,,11.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.95,90,,12.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.7,32.15,,4.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.7,32.15,,4.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.59,88,,12.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.87,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.7,15.95,
AROM-COT,499991,CDM,270,RC,,,Outpatient,,,17.75,10.65,,15.09,85,,12.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.21,80.03,,11.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.98,90,,12.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.62,88,,12.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.98,
KIWI IGE ALLERGEN   (MAYO),1186004,CDM,300,RC,86003,HCPCS,Outpatient,,,17.75,10.65,,15.09,85,,12.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.21,80.03,,11.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.98,90,,12.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.62,88,,12.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,15.98,
RBC COUNT,1885041,CDM,300,RC,85041,HCPCS,Outpatient,,,17.75,10.65,,15.09,85,,12.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.21,80.03,,11.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,15.98,90,,12.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.62,88,,12.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.89,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.78,15.98,
SPORANOX (itraconazole) 100MG CAP,29521,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
MISC DRUG 15,29903,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
MARCAINE/SENSORCAINE (BUPIV)0.75%-MPF 30,292007,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
PREDNISOLONE 15MG/5ML : 1OZ,292267,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
PEPCID (FAMOTIDINE) : 20MG VIAL,293370,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
NUPERCAINAL (DIBUCAINE) OINT 2OZ,297042,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
ISOPTO ATROPINE 1% O/S,297703,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.77,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
DEBROX EAR DROPS (CARBAMIDE PEROX) 15ML,297806,CDM,250,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.77,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
STREPTOMYCIN: 1GM INJ,293177,CDM,636,RC,J3000,HCPCS,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.77,,,,Other,Not Separately reimbursable,33.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.22,33.37,
MISC PHARMACY ADDITIVE,293500,CDM,636,RC,,,Outpatient,,,17.77,10.66,,15.1,85,,12.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.22,80.03,,11.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.99,90,,12.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.77,,,,Other,Not Separately reimbursable,5.71,32.15,,4.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.64,88,,12.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.88,33.11,,4.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.71,15.99,
Collection of venous blood by venipuncture,1836415,CDM,300,RC,36415,HCPCS,Outpatient,,,17.84,10.7,,15.16,85,,12.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.74,32.15,,4.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.28,80.03,,11.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,16.06,90,,12.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.74,32.15,,4.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.74,32.15,,4.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.7,88,,12.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.91,33.11,,4.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.74,16.06,
LIDOCAINE 2GM/500ML DRIP (0.4%),296157,CDM,258,RC,J2001,HCPCS,Outpatient,,,17.96,10.78,,15.27,85,,12.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.37,80.03,,11.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.16,90,,12.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.8,88,,12.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,16.16,
NORMODYNE (labetalol)  20MG/4ML,293409,CDM,250,RC,,,Outpatient,,,18,10.8,,15.3,85,,12.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.41,80.03,,11.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,12.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.84,88,,12.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.96,33.11,,4.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.79,16.2,
NOVOLOG (aspart) 70/30 MIX INSULIN,293410,CDM,250,RC,J1815,HCPCS,Outpatient,,,18,10.8,,15.3,85,,12.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.41,80.03,,11.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,12.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.84,88,,12.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,16.2,
VYVANSE (lisdexamphetamine)  70MG TAB,294047,CDM,250,RC,,,Outpatient,,,18,10.8,,15.3,85,,12.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.41,80.03,,11.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,12.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.84,88,,12.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.96,33.11,,4.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.79,16.2,
BROMFED DM SYRUP: 1OZ,295107,CDM,250,RC,,,Outpatient,,,18,10.8,,15.3,85,,12.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.41,80.03,,11.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,12.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.84,88,,12.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.96,33.11,,4.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.79,16.2,
DRESSING ALLDRESS 4 X 4,491528,CDM,270,RC,,,Outpatient,,,18,10.8,,15.3,85,,12.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.41,80.03,,11.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,12.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.79,32.15,,4.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.84,88,,12.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.96,33.11,,4.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.79,16.2,
PINEAPPLE IGE ALLERGEN   (MAYO),1186005,CDM,300,RC,86003,HCPCS,Outpatient,,,18,10.8,,15.3,85,,12.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.41,80.03,,11.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,16.2,90,,12.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.84,88,,12.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,16.2,
INAPSINE (droperidol) 2.5MG/ML 2 ML inj,293244,CDM,636,RC,J1790,HCPCS,Outpatient,,,18,10.8,,15.3,85,,12.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.41,80.03,,11.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,12.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,8.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.84,88,,12.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.22,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.95,16.2,
FLU VACC(INFLUENZA-CLARY ONLY) 0.5ML,293522,CDM,636,RC,Q2038,HCPCS,Outpatient,,,18.05,10.83,,15.34,85,,12.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.8,32.15,,4.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.45,80.03,,11.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.25,90,,13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.8,32.15,,4.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.8,32.15,,4.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.88,88,,12.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.98,33.11,,4.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.8,16.25,
ISOMIL DF : INFANT FORM 946ML,292335,CDM,250,RC,,,Outpatient,,,18.25,10.95,,15.51,85,,12.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.61,80.03,,11.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.43,90,,13.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.06,88,,12.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.04,33.11,,4.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.87,16.43,
"THYROGLOBULIN, TUMOR MARKER  (MAYO)",1886802,CDM,300,RC,84432,HCPCS,Outpatient,,,18.25,10.95,,15.51,85,,12.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.61,80.03,,11.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,16.43,90,,13.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.06,88,,12.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.61,20.2,
PULSE OXIMETRY,30375,CDM,460,RC,94760,HCPCS,Outpatient,,,18.25,10.95,,15.51,85,,12.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.61,80.03,,11.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.43,90,,13.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.06,88,,12.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.04,33.11,,4.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.87,16.43,
"EAR, PULSE OXIMETRY MULTI DETERMINATIONS",30376,CDM,460,RC,94761,HCPCS,Outpatient,,,18.25,10.95,,15.51,85,,12.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.61,80.03,,11.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.43,90,,13.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.87,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.06,88,,12.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.04,33.11,,4.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.87,16.43,
ISUPREL MISTOMETER 22.5ML,292042,CDM,250,RC,,,Outpatient,,,18.29,10.97,,15.55,85,,12.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.88,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.64,80.03,,11.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.46,90,,13.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.88,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.29,,,,Other,Not Separately reimbursable,5.88,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.1,88,,12.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.06,33.11,,4.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.88,16.46,
CORTICAINE 0.5% (HYDROCORTISONE) CRM:1OZ,297012,CDM,250,RC,,,Outpatient,,,18.29,10.97,,15.55,85,,12.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.88,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.64,80.03,,11.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.46,90,,13.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.88,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.29,,,,Other,Not Separately reimbursable,5.88,32.15,,4.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.1,88,,12.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.06,33.11,,4.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.88,16.46,
COGENTIN (benztropine): 2MG/2ML AMP,293044,CDM,636,RC,J0515,HCPCS,Outpatient,,,18.29,10.97,,15.55,85,,12.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.64,80.03,,11.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.46,90,,13.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.29,,,,Other,Not Separately reimbursable,22.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.1,88,,12.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.64,22.28,
ACTOS (pioglitazone) 45MG,29115,CDM,250,RC,,,Outpatient,,,18.35,11.01,,15.6,85,,12.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.69,80.03,,11.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,90,,13.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.35,,,,Other,Not Separately reimbursable,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.15,88,,12.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.08,33.11,,4.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.9,16.52,
CEFZIL (CEFPROZIL) 500MG TAB,29858,CDM,250,RC,,,Outpatient,,,18.35,11.01,,15.6,85,,12.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.69,80.03,,11.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,90,,13.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.15,88,,12.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.08,33.11,,4.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.9,16.52,
ESTRADERM (estradiol) 0.75MG PATCH,292102,CDM,250,RC,,,Outpatient,,,18.35,11.01,,15.6,85,,12.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.69,80.03,,11.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,90,,13.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.15,88,,12.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.08,33.11,,4.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.9,16.52,
ESTRADERM (estradiol) 0.05MG PATCH,292104,CDM,250,RC,,,Outpatient,,,18.35,11.01,,15.6,85,,12.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.69,80.03,,11.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,90,,13.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.15,88,,12.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.08,33.11,,4.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.9,16.52,
ESTRADERM (estradiol) 0.1MG PATCH,292110,CDM,250,RC,,,Outpatient,,,18.35,11.01,,15.6,85,,12.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.69,80.03,,11.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,90,,13.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.15,88,,12.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.08,33.11,,4.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.9,16.52,
DRESSING EAKIN COHESIVE SKIN BARRIER4  D,4393,CDM,270,RC,,,Outpatient,,,18.35,11.01,,15.6,85,,12.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.69,80.03,,11.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,90,,13.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.9,32.15,,4.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.15,88,,12.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.08,33.11,,4.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.9,16.52,
HALDOL (HALOPERIDOL) : 5MG INJ,293232,CDM,636,RC,J1630,HCPCS,Outpatient,,,18.35,11.01,,15.6,85,,12.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.69,80.03,,11.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.52,90,,13.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.15,88,,12.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.24,16.52,
MEFOXIN (cefoxitin) : 1GM VIAL,293363,CDM,636,RC,J0694,HCPCS,Outpatient,,,18.38,11.03,,15.62,85,,12.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.71,80.03,,11.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.54,90,,13.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.17,88,,12.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.17,16.54,
SOLUTION BETADINE 4OZ,491500,CDM,270,RC,,,Outpatient,,,18.45,11.07,,15.68,85,,12.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.93,32.15,,4.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.77,80.03,,11.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.61,90,,13.29,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.93,32.15,,4.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.93,32.15,,4.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.24,88,,12.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.11,33.11,,4.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.93,16.61,
POTASSIUM CL 40MEQ/ 30ML ORAL SOLN,292265,CDM,250,RC,,,Outpatient,,,18.5,11.1,,15.73,85,,12.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.95,32.15,,4.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.81,80.03,,11.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.65,90,,13.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.95,32.15,,4.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.95,32.15,,4.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.28,88,,13.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.13,33.11,,4.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5.95,16.65,
SOLU MEDROL (methylprednisolone)40MG INJ,293169,CDM,636,RC,J2920,HCPCS,Outpatient,,,18.5,11.1,,15.73,85,,12.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.81,80.03,,11.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.65,90,,13.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.28,88,,13.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.43,16.65,
SOLU MEDROL 40MG - wt based dosing,295033,CDM,636,RC,J2920,HCPCS,Outpatient,,,18.5,11.1,,15.73,85,,12.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.81,80.03,,11.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.65,90,,13.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.28,88,,13.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.43,16.65,
Blood test to diagnose HIV,1183890,CDM,300,RC,86703,HCPCS,Outpatient,,,18.55,11.13,,15.77,85,,12.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.85,80.03,,11.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.98,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,16.7,90,,13.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.98,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.32,88,,13.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.85,16.7,
BLADE #10 SCALPEL DISPOSABLE,49229,CDM,270,RC,,,Outpatient,,,18.66,11.2,,15.86,85,,12.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6,32.15,,4.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.93,80.03,,11.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.79,90,,13.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6,32.15,,4.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6,32.15,,4.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.42,88,,13.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.18,33.11,,4.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6,16.79,
PAD MAGNETIC INSTRUMENT 10 X16  STERILE,49675,CDM,270,RC,,,Outpatient,,,18.75,11.25,,15.94,85,,12.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.03,32.15,,4.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.01,80.03,,12.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.88,90,,13.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.03,32.15,,4.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.03,32.15,,4.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.5,88,,13.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.21,33.11,,4.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.03,16.88,
CO2 (BICARBONATE),1882374,CDM,300,RC,82374,HCPCS,Outpatient,,,18.75,11.25,,15.94,85,,12.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.01,80.03,,12.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.97,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,16.88,90,,13.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.97,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.5,88,,13.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.15,16.88,
CHLORIDE,1882435,CDM,300,RC,82435,HCPCS,Outpatient,,,18.75,11.25,,15.94,85,,12.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.01,80.03,,12.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,16.88,90,,13.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.5,88,,13.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.78,16.88,
"URINE CHLORIDE, RANDOM",1882436,CDM,300,RC,82436,HCPCS,Outpatient,,,18.75,11.25,,15.94,85,,12.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.01,80.03,,12.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,16.88,90,,13.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.5,88,,13.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,16.88,
XARELTO (rivaroxaban) 10MG TAB,29181,CDM,250,RC,,,Outpatient,,,18.79,11.27,,15.97,85,,12.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.04,80.03,,12.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.91,90,,13.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.79,,,,Other,Not Separately reimbursable,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.54,88,,13.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.22,33.11,,4.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.04,16.91,
XYLOCAINE 4% (LIDOCAINE) TOPICAL U/D,293326,CDM,250,RC,,,Outpatient,,,18.8,11.28,,15.98,85,,12.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.05,80.03,,12.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.92,90,,13.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.8,,,,Other,Not Separately reimbursable,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.54,88,,13.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.22,33.11,,4.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.04,16.92,
"WYCILLIN (pen G procaine)1,200,000 units",296066,CDM,250,RC,,,Outpatient,,,18.8,11.28,,15.98,85,,12.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.05,80.03,,12.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.92,90,,13.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.54,88,,13.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.22,33.11,,4.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.04,16.92,
ACHROMYCIN OPTH SUSP 1%,297701,CDM,250,RC,,,Outpatient,,,18.8,11.28,,15.98,85,,12.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.05,80.03,,12.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.92,90,,13.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.54,88,,13.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.22,33.11,,4.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.04,16.92,
DACRIOSE (eye wash soln) 120 ML,297744,CDM,250,RC,,,Outpatient,,,18.8,11.28,,15.98,85,,12.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.05,80.03,,12.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.92,90,,13.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.54,88,,13.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.22,33.11,,4.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.04,16.92,
GELFOAM POWDER 10GM,298023,CDM,250,RC,,,Outpatient,,,18.8,11.28,,15.98,85,,12.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.05,80.03,,12.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.92,90,,13.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.04,32.15,,4.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.54,88,,13.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.22,33.11,,4.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.04,16.92,
CYMBALTA (duloxetine) 30MG CAP,29881,CDM,250,RC,,,Outpatient,,,18.82,11.29,,16,85,,12.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.05,32.15,,4.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.06,80.03,,12.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.94,90,,13.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.05,32.15,,4.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.05,32.15,,4.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.56,88,,13.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.23,33.11,,4.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.05,16.94,
THYMOL IODIDE POWDER 3GM,29558,CDM,250,RC,,,Outpatient,,,19,11.4,,16.15,85,,12.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.21,80.03,,12.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,90,,13.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.72,88,,13.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.29,33.11,,5.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.11,17.1,
EXELON (rivastigmine) 4.6MG/24HR PATCH,291167,CDM,250,RC,,,Outpatient,,,19,11.4,,16.15,85,,12.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.21,80.03,,12.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,90,,13.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.72,88,,13.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.29,33.11,,5.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.11,17.1,
TENSILON 10MG/ML INJ : 10ML,293184,CDM,250,RC,,,Outpatient,,,19,11.4,,16.15,85,,12.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.21,80.03,,12.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,90,,13.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.72,88,,13.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.29,33.11,,5.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.11,17.1,
TEMPRA (ACETAMINOPHEN) DROPS: 15ML,294033,CDM,250,RC,,,Outpatient,,,19,11.4,,16.15,85,,12.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.21,80.03,,12.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,90,,13.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.11,32.15,,4.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.72,88,,13.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.29,33.11,,5.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.11,17.1,
Blood test to measure the level of lipoproteins in the blood,1883706,CDM,300,RC,83718,HCPCS,Outpatient,,,19,11.4,,16.15,85,,12.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.21,80.03,,12.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,17.1,90,,13.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.72,88,,13.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.3,17.1,
DRESSING XEROFORM 1 X 8,491399,CDM,270,RC,,,Outpatient,,,19.07,11.44,,16.21,85,,12.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.13,32.15,,4.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.26,80.03,,12.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.16,90,,13.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.13,32.15,,4.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.13,32.15,,4.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.78,88,,13.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.31,33.11,,5.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.13,17.16,
ACTIV CHARCOAL W/O SORB. : 25GM,295503,CDM,250,RC,,,Outpatient,,,19.1,11.46,,16.24,85,,12.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.14,32.15,,4.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.29,80.03,,12.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.19,90,,13.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.14,32.15,,4.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.14,32.15,,4.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,88,,13.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.32,33.11,,5.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.14,17.19,
"EDEMA GLOVE, EA",401,CDM,270,RC,E1399,HCPCS,Outpatient,,,19.25,11.55,,16.36,85,,13.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.19,32.15,,4.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.41,80.03,,12.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.33,90,,13.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.19,32.15,,4.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.19,32.15,,4.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.94,88,,13.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.37,33.11,,5.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.19,17.33,
THYROID BINDING GLOBULIN  (MAYO),1884442,CDM,300,RC,84442,HCPCS,Outpatient,,,19.25,11.55,,16.36,85,,13.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.41,80.03,,12.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.07,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,17.33,90,,13.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.07,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.94,88,,13.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,17.33,
MARCAINE/SENSORCAINE 0.5% W/EPI-MPF 10ML,293465,CDM,250,RC,,,Outpatient,,,19.3,11.58,,16.41,85,,13.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.2,32.15,,4.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.45,80.03,,12.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.37,90,,13.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.2,32.15,,4.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.2,32.15,,4.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.98,88,,13.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.39,33.11,,5.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.2,17.37,
KENALOG (triamcinolone) 10MG INJ 1ML,293090,CDM,636,RC,J3301,HCPCS,Outpatient,,,19.3,11.58,,16.41,85,,13.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.45,80.03,,12.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.37,90,,13.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.98,88,,13.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.19,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.16,17.37,
ATIVAN (lorazepam)INJ 2MG/ML 10 ML VIAL,293113,CDM,636,RC,J2060,HCPCS,Outpatient,,,19.3,11.58,,16.41,85,,13.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.2,32.15,,4.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.45,80.03,,12.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.37,90,,13.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.2,32.15,,4.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.2,32.15,,4.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.98,88,,13.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.39,33.11,,5.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.2,17.37,
DEPAKENE (valproic acid) 250MG/5ML 1OZ,292220,CDM,250,RC,,,Outpatient,,,19.32,11.59,,16.42,85,,13.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.46,80.03,,12.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.39,90,,13.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17,88,,13.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.4,33.11,,5.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.21,17.39,
LOPRESSOR (metoprolol) :5MG/5ML INJ,293271,CDM,250,RC,,,Outpatient,,,19.32,11.59,,16.42,85,,13.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.46,80.03,,12.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.39,90,,13.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17,88,,13.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.4,33.11,,5.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.21,17.39,
MAXITROL (dexa/neo/polymix) OPTH SOLN5ML,297721,CDM,250,RC,,,Outpatient,,,19.33,11.6,,16.43,85,,13.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.47,80.03,,12.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.4,90,,13.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.21,32.15,,4.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,88,,13.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.4,33.11,,5.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.21,17.4,
AQUAMEPHYTON (vitamin K) 1MG/0.5ML INJ,293015,CDM,636,RC,J3430,HCPCS,Outpatient,,,19.33,11.6,,16.43,85,,13.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.47,80.03,,12.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.4,90,,13.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.01,88,,13.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.98,17.4,
BANDAGE ELST MATRIX STRL 4 X10YD,493054,CDM,270,RC,,,Outpatient,,,19.38,11.63,,16.47,85,,13.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.23,32.15,,4.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.51,80.03,,12.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.44,90,,13.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.23,32.15,,4.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.23,32.15,,4.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.05,88,,13.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.42,33.11,,5.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.23,17.44,
E-TEST GRADIENT STRIP,1887181,CDM,300,RC,87181,HCPCS,Outpatient,,,19.38,11.63,,16.47,85,,13.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.51,80.03,,12.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,17.44,90,,13.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.05,88,,13.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,17.44,
NEEDLE SPINAL WHITACRE 25GA X 3 1/2,491660,CDM,270,RC,,,Outpatient,,,19.42,11.65,,16.51,85,,13.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.24,32.15,,4.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.54,80.03,,12.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,90,,13.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.24,32.15,,4.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.24,32.15,,4.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.09,88,,13.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.43,33.11,,5.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.24,17.48,
BRILINTA (ticagrelor) 90MG TAB,291163,CDM,250,RC,,,Outpatient,,,19.43,11.66,,16.52,85,,13.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.25,32.15,,5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.55,80.03,,12.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.49,90,,13.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.25,32.15,,5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.25,32.15,,5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.1,88,,13.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.43,33.11,,5.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.25,17.49,
PREVACID (lansoprazole) 15 MG SOLUT-NF,291026,CDM,250,RC,,,Outpatient,,,19.5,11.7,,16.58,85,,13.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.61,80.03,,12.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.55,90,,14.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.16,88,,13.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.46,33.11,,5.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.27,17.55,
PONTOCAINE 1% 2ML AMP,297523,CDM,250,RC,,,Outpatient,,,19.5,11.7,,16.58,85,,13.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.61,80.03,,12.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.55,90,,14.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.16,88,,13.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.46,33.11,,5.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.27,17.55,
.T-PIECE,30215,CDM,270,RC,,,Outpatient,,,19.5,11.7,,16.58,85,,13.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.61,80.03,,12.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.55,90,,14.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.27,32.15,,5.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.16,88,,13.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.46,33.11,,5.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.27,17.55,
COLD AGGLUTININ SCREEN  (MAYO),1886004,CDM,300,RC,86157,HCPCS,Outpatient,,,19.5,11.7,,16.58,85,,13.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.61,80.03,,12.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,17.55,90,,14.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.16,88,,13.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.14,17.55,
ACETONE,1882009,CDM,300,RC,82009,HCPCS,Outpatient,,,19.75,11.85,,16.79,85,,13.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.81,80.03,,12.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,17.78,90,,14.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.38,88,,13.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.25,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.13,17.78,
ISUPREL MISTOMETER 15ML,292041,CDM,250,RC,,,Outpatient,,,19.83,11.9,,16.86,85,,13.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.87,80.03,,12.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.85,90,,14.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.45,88,,13.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.57,33.11,,5.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.38,17.85,
ROWASA (mesalamine) 4GM SUSP,295111,CDM,250,RC,,,Outpatient,,,19.83,11.9,,16.86,85,,13.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.87,80.03,,12.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.85,90,,14.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.83,,,,Other,Not Separately reimbursable,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.45,88,,13.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.57,33.11,,5.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.38,17.85,
INFLAMASE 1/8% 5ML,297713,CDM,250,RC,,,Outpatient,,,19.83,11.9,,16.86,85,,13.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.87,80.03,,12.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.85,90,,14.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.83,,,,Other,Not Separately reimbursable,6.38,32.15,,5.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.45,88,,13.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.57,33.11,,5.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.38,17.85,
XYLOCAINE (LIDOCAINE) 100MG/5ML INJ (ABJ,293222,CDM,636,RC,J2001,HCPCS,Outpatient,,,19.83,11.9,,16.86,85,,13.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.87,80.03,,12.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.85,90,,14.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.83,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.45,88,,13.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,17.85,
COBAN 1  ROLL,419,CDM,270,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
DRESSING EAKIN COHESIVE SKIN BARRIER 4X8,4392,CDM,270,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
SPIROMETRY MOUTHPIECE,30150,CDM,270,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
DO NOT USE,31109,CDM,270,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
"OXALATE, 24HR URINE  (MAYO)",1882200,CDM,300,RC,83945,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.01,18,
"PH, 24HR URINE  (MAYO)",1882201,CDM,300,RC,83986,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.5,18,
Blood test to screen for antibodies that could harm red blood cells,1886006,CDM,300,RC,86850,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,15.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.23,18,
P/T CPM TREATMENT/CHECK,31106,CDM,420,RC,97139,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
Form of decompression therapy of the spine,31113,CDM,420,RC,97012,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
ELECTRO-MANUAL,31405,CDM,420,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
MANUAL TRACTION,31406,CDM,420,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
P/T DEBRIDEMENT SKIN,3112054,CDM,420,RC,97139,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
ULTRASOUND WITH STIM,31408,CDM,430,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
FITTING PRE-FAB SPLINT STATIC,313005,CDM,430,RC,97504,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
Occupational therapy,313007,CDM,430,RC,97535,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
Occupational therapy,313008,CDM,430,RC,97535,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",313010,CDM,430,RC,97110,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
One time use unattended,313014,CDM,430,RC,97014,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
FLUIDO,313017,CDM,430,RC,97039,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,313018,CDM,430,RC,97033,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",313019,CDM,430,RC,97035,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
ARM HAND EX ADD 15 MIN,313031,CDM,430,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
ADL TRAINING II,3197541,CDM,430,RC,,,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.43,32.15,,5.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.62,33.11,,5.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.43,18,
ANCEF (cefazolin) : 500MG VIAL,293345,CDM,636,RC,J0690,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,18,
ANCEF (cefazolin) : 1GM VIAL,293346,CDM,636,RC,J0690,HCPCS,Outpatient,,,20,12,,17,85,,13.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.01,80.03,,12.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,14.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.6,88,,14.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,18,
NOVOLOG (aspart) 100 UNITS/ML INSULIN,293479,CDM,250,RC,J1815,HCPCS,Outpatient,,,20.1,12.06,,17.09,85,,13.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.09,80.03,,12.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.09,90,,14.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.69,88,,14.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,18.09,
XYLOCAINE 1% (LIDOCAINE)STERILEJELLY:5ML,293440,CDM,250,RC,,,Outpatient,,,20.14,12.08,,17.12,85,,13.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.48,32.15,,5.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.12,80.03,,12.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.13,90,,14.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.48,32.15,,5.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.48,32.15,,5.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.72,88,,14.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.67,33.11,,5.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.48,18.13,
GEODON (ziprasidone) 20MG CAP,293490,CDM,250,RC,,,Outpatient,,,20.2,12.12,,17.17,85,,13.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.49,32.15,,5.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.17,80.03,,12.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.18,90,,14.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.49,32.15,,5.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.49,32.15,,5.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.78,88,,14.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.69,33.11,,5.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.49,18.18,
NARCAN (naloxone) 0.4MG/ML INJ,293120,CDM,636,RC,J2310,HCPCS,Outpatient,,,20.2,12.12,,17.17,85,,13.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.17,80.03,,12.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.18,90,,14.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.78,88,,14.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.54,18.18,
EQUIPMENT ROUNDS,3025,CDM,270,RC,,,Outpatient,,,20.25,12.15,,17.21,85,,13.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.21,80.03,,12.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.23,90,,14.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.82,88,,14.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.7,33.11,,5.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.51,18.23,
BANDAGE GAUZE 4 X75  STRETCH STERILE,49136,CDM,270,RC,,,Outpatient,,,20.25,12.15,,17.21,85,,13.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.21,80.03,,12.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.23,90,,14.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.82,88,,14.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.7,33.11,,5.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.51,18.23,
DRESSING CUTIMED 6 X6  SILTEC B,49296,CDM,270,RC,,,Outpatient,,,20.25,12.15,,17.21,85,,13.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.21,80.03,,12.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.23,90,,14.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.82,88,,14.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.7,33.11,,5.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.51,18.23,
URINE COLLECTOR NEWBORN,490070,CDM,270,RC,,,Outpatient,,,20.25,12.15,,17.21,85,,13.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.21,80.03,,12.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.23,90,,14.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.82,88,,14.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.7,33.11,,5.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.51,18.23,
BAG EVACUTION FLATUS BAG/RECTAL TUBE,493776,CDM,270,RC,,,Outpatient,,,20.25,12.15,,17.21,85,,13.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.21,80.03,,12.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.23,90,,14.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.25,,,,Other,Not Separately reimbursable,6.51,32.15,,5.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.82,88,,14.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.7,33.11,,5.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.51,18.23,
"MAGNESIUM, 24HR URINE  (MAYO)",1882195,CDM,300,RC,83735,HCPCS,Outpatient,,,20.25,12.15,,17.21,85,,13.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.21,80.03,,12.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18.23,90,,14.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.82,88,,14.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.42,18.23,
BANDAGE GAUZE 2 X75  STRETCH STERILE,49134,CDM,270,RC,,,Outpatient,,,20.3,12.18,,17.26,85,,13.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.53,32.15,,5.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.25,80.03,,13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.27,90,,14.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.53,32.15,,5.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.3,,,,Other,Not Separately reimbursable,6.53,32.15,,5.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.86,88,,14.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.72,33.11,,5.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.53,18.27,
CLEANSER BODY FOAMING 5 OZ REMEDY,498020,CDM,270,RC,,,Outpatient,,,20.3,12.18,,17.26,85,,13.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.53,32.15,,5.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.25,80.03,,13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.27,90,,14.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.53,32.15,,5.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.3,,,,Other,Not Separately reimbursable,6.53,32.15,,5.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.86,88,,14.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.72,33.11,,5.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.53,18.27,
LO-SO BOWEL PREP KIT,292003,CDM,250,RC,,,Outpatient,,,20.33,12.2,,17.28,85,,13.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,80.03,,13.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.3,90,,14.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.33,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.89,88,,14.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.73,33.11,,5.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.3,
XYLOCAINE 1% W/EPI: 5ML,293514,CDM,250,RC,,,Outpatient,,,20.35,12.21,,17.3,85,,13.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.29,80.03,,13.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,90,,14.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.35,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.91,88,,14.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.74,33.11,,5.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.32,
XYLOC1%  W/EPI (LIDO1/EPI200K); SDV 10ML,293539,CDM,250,RC,,,Outpatient,,,20.35,12.21,,17.3,85,,13.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.29,80.03,,13.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,90,,14.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.35,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.91,88,,14.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.74,33.11,,5.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.32,
NE0-DECADRON CR,297074,CDM,250,RC,,,Outpatient,,,20.35,12.21,,17.3,85,,13.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.29,80.03,,13.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,90,,14.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.35,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.91,88,,14.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.74,33.11,,5.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.32,
LACRI-LUBE (art.tears) OINT 3.5GM,297517,CDM,250,RC,,,Outpatient,,,20.35,12.21,,17.3,85,,13.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.29,80.03,,13.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,90,,14.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.35,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.91,88,,14.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.74,33.11,,5.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.32,
EPPY-N 1% OPTH OINT7.5ML,297708,CDM,250,RC,,,Outpatient,,,20.35,12.21,,17.3,85,,13.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.29,80.03,,13.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,90,,14.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.35,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.91,88,,14.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.74,33.11,,5.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.32,
TEARISOL (ART.TEARS) SOLN 15ML,297731,CDM,250,RC,,,Outpatient,,,20.35,12.21,,17.3,85,,13.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.29,80.03,,13.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,90,,14.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.35,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.91,88,,14.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.74,33.11,,5.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.32,
PILOCARPINE 2% OPHTH SOLN 15 ML,297742,CDM,250,RC,,,Outpatient,,,20.35,12.21,,17.3,85,,13.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.29,80.03,,13.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.32,90,,14.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.35,,,,Other,Not Separately reimbursable,6.54,32.15,,5.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.91,88,,14.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.74,33.11,,5.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.54,18.32,
SEROQUEL (quetiapine) 200 MG TAB,291156,CDM,250,RC,,,Outpatient,,,20.4,12.24,,17.34,85,,13.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.56,32.15,,5.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.33,80.03,,13.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,90,,14.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.56,32.15,,5.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.4,,,,Other,Not Separately reimbursable,6.56,32.15,,5.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.95,88,,14.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.75,33.11,,5.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.56,18.36,
SEAL EAKIN COHESIVE,491533,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
CANNULA VACURETTE STRAIGHT 9MM BERKELEY,491796,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
CANNULA VACURETTE CURVED 12MM BERKELEY,491797,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
CANNULA VACURETTE STRAIGHT 12MM BERKELEY,491798,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
VALVE ENDOSCOPY BIOPSY SINGLE USE,492191,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
CATH IV INTROCAN 22G X 1,496309,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
CATH IV INTROCAN 24G X 3/4,496310,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
DRESSING FOAM 2 X2  HYDRO BLUE,498050,CDM,270,RC,,,Outpatient,,,20.5,12.3,,17.43,85,,13.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.41,80.03,,13.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.45,90,,14.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.59,32.15,,5.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.04,88,,14.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.79,33.11,,5.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.59,18.45,
AMPICILLIN : 1GM VIAL,293344,CDM,636,RC,J0290,HCPCS,Outpatient,,,20.73,12.44,,17.62,85,,14.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.59,80.03,,13.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.66,90,,14.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.24,88,,14.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,18.66,
PLASTIC SHOE HORN,404,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
SHOE BUTTON,417,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
"ELECTRODES, BIOFEEDBACK, SET OF 3",420,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
NOSEY CUP,441,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CATHETER PLUG,49530,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CATH SUCTION 8FR DELEE TIP,49735,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CATH SUCTION 10FR W/DELEE TIP,49744,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CATH SUCTION 14FR STRAIGHT,49756,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CATH SUCTION 18FR,49768,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CATH SUCTION 12FR WHISTLE TIP,49774,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CANNULA VACURETTE CURVED 8MM BERKELEY,491801,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
STOPCOCK THREE-WAY W/TUBE,493289,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
SET EXTENSION 2C-6224,493290,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
STERI-STRIPS 1/8 X 3,493311,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
SET DEXTROLYTE II SINGLE USE Y-TUBING,498002,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.75,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
WIRE GUIDE SUBCLAVIAN JUGULAR,4916592,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.75,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
SET Y FREEDOM W/DISINFECTANT AND SNAP DI,4980079,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.75,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
CAP SEALING ADAPTOR CATHETER,4980085,CDM,270,RC,,,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.75,,,,Other,Not Separately reimbursable,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
FIBROSURE BILIRUBIN TOTAL (MAYO),1883879,CDM,300,RC,82247,HCPCS,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,18.68,
Blood test to evaluate liver function,1883884,CDM,300,RC,84460,HCPCS,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,18.68,
WBC,1885048,CDM,300,RC,85048,HCPCS,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.2,18.68,
PLATELET COUNT,1885595,CDM,300,RC,85049,HCPCS,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.63,18.68,
Collection of venous blood by venipuncture,2036415,CDM,300,RC,36415,HCPCS,Outpatient,,,20.75,12.45,,17.64,85,,14.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.61,80.03,,13.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18.68,90,,14.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.67,32.15,,5.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.26,88,,14.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.87,33.11,,5.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.67,18.68,
HAND EXERCISER,59307,CDM,270,RC,,,Outpatient,,,20.9,12.54,,17.77,85,,14.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.72,32.15,,5.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.73,80.03,,13.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,90,,15.05,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.72,32.15,,5.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.9,,,,Other,Not Separately reimbursable,6.72,32.15,,5.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.39,88,,14.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.92,33.11,,5.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.72,18.81,
MYCOBUTIN (RIFABUTIN) 150MG,29684,CDM,250,RC,,,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
KETEK (TELITHROMYCIN) 400MG TAB,293481,CDM,250,RC,,,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
STERI-STRIPS 1/4 X 4,493317,CDM,270,RC,,,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
KIT TELEMETRY STEPDOWN,498499,CDM,270,RC,,,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
FLUSH- PICC LINE  (NS FLUSH- PRN ADMINS),293546,CDM,272,RC,A4218,HCPCS,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
FLUSH- PICC LINE  (NS ) DAILY FLUSH,293577,CDM,272,RC,A4218,HCPCS,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
Blood test to determine if antibodies exist for rubella,1886280,CDM,300,RC,86762,HCPCS,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,18.9,
COLD PACK,531794,CDM,540,RC,,,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
BENADRYL INJ.,533024,CDM,540,RC,,,Outpatient,,,21,12.6,,17.85,85,,14.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.81,80.03,,13.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,15.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21,,,,Other,Not Separately reimbursable,6.75,32.15,,5.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.48,88,,14.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,33.11,,5.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.75,18.9,
CATAPRES (CLONIDINE) TTS-1 PATCH,292096,CDM,250,RC,,,Outpatient,,,21.12,12.67,,17.95,85,,14.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.9,80.03,,13.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.01,90,,15.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.12,,,,Other,Not Separately reimbursable,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.59,88,,14.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.99,33.11,,5.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.79,19.01,
ACTIV CHARCOAL W/SOR : 25GM/120ML,295502,CDM,250,RC,,,Outpatient,,,21.12,12.67,,17.95,85,,14.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.9,80.03,,13.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.01,90,,15.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.12,,,,Other,Not Separately reimbursable,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.59,88,,14.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.99,33.11,,5.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.79,19.01,
EMLA CREAM TOPICAL,297091,CDM,250,RC,,,Outpatient,,,21.12,12.67,,17.95,85,,14.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.9,80.03,,13.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.01,90,,15.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.12,,,,Other,Not Separately reimbursable,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.59,88,,14.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.99,33.11,,5.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.79,19.01,
ISOPTO HOMATROPINE2% O/S,297718,CDM,250,RC,,,Outpatient,,,21.12,12.67,,17.95,85,,14.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.9,80.03,,13.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.01,90,,15.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.12,,,,Other,Not Separately reimbursable,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.59,88,,14.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.99,33.11,,5.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.79,19.01,
QUELICIN (SUCCINYL CHOLINE) 100MG/ML INJ,296048,CDM,636,RC,J0330,HCPCS,Outpatient,,,21.12,12.67,,17.95,85,,14.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.9,80.03,,13.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.01,90,,15.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.12,,,,Other,Not Separately reimbursable,6.79,32.15,,5.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.59,88,,14.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.99,33.11,,5.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.79,19.01,
TUBE ENDOTRACH 7.5MM NASAL RAE,493803,CDM,270,RC,,,Outpatient,,,21.15,12.69,,17.98,85,,14.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.8,32.15,,5.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.93,80.03,,13.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.04,90,,15.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.8,32.15,,5.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.15,,,,Other,Not Separately reimbursable,6.8,32.15,,5.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.61,88,,14.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7,33.11,,5.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.8,19.04,
CALCIUM CHLORIDE 10%: 10ML SYRINGE,293030,CDM,250,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.25,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
CANNULA VACURETTE STRAIGHT 8MM BERKELEY,491799,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.25,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
CANNULA VACURETTE F TIP 6MM FLEX D & C,491800,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.25,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
CANNULA VACURETTE STRAIGHT 10MM BERKELEY,491802,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.25,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
CANNULA VACURETTE STRAIGHT 11MM BERKELEY,491803,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.25,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
CANNULA VACURETTE CURVED 9MM BERKELEY,491804,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
CANNULA VACURETTE CURVED 11MM BERKELEY,491806,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
CANNULA VACURETTE FLEX TIP 7MM,491818,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
STERI-STRIPS 1/4 X 3,493310,CDM,270,RC,,,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.83,32.15,,5.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.04,33.11,,5.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.83,19.13,
"IMMUNOGLOBULIN E, IGE  (MAYO)",1882785,CDM,300,RC,82785,HCPCS,Outpatient,,,21.25,12.75,,18.06,85,,14.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.01,80.03,,13.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.13,90,,15.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.7,88,,14.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.01,20.71,
COLOCORT (hydrocort) 100 MG /60ML SUSP,295114,CDM,250,RC,,,Outpatient,,,21.33,12.8,,18.13,85,,14.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.86,32.15,,5.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.07,80.03,,13.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.2,90,,15.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.86,32.15,,5.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,6.86,32.15,,5.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.77,88,,15.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.06,33.11,,5.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.86,19.2,
CRESTOR (rosuvastatin)20MG TAB,29581,CDM,250,RC,,,Outpatient,,,21.46,12.88,,18.24,85,,14.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.9,32.15,,5.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.17,80.03,,13.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.31,90,,15.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.9,32.15,,5.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.46,,,,Other,Not Separately reimbursable,6.9,32.15,,5.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.88,88,,15.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.11,33.11,,5.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.9,19.31,
ZYVOX (linezolid) 600MG TAB,293473,CDM,250,RC,,,Outpatient,,,21.5,12.9,,18.28,85,,14.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.91,32.15,,5.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.21,80.03,,13.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.35,90,,15.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.91,32.15,,5.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.5,,,,Other,Not Separately reimbursable,6.91,32.15,,5.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.92,88,,15.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.12,33.11,,5.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.91,19.35,
CANNULA VACURETTE CURVED 10MM BERKELEY,491805,CDM,270,RC,,,Outpatient,,,21.5,12.9,,18.28,85,,14.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.91,32.15,,5.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.21,80.03,,13.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.35,90,,15.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.91,32.15,,5.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.5,,,,Other,Not Separately reimbursable,6.91,32.15,,5.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.92,88,,15.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.12,33.11,,5.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.91,19.35,
"PENICILLIN G, IGE  (MAYO)",1882687,CDM,300,RC,86003,HCPCS,Outpatient,,,21.5,12.9,,18.28,85,,14.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.21,80.03,,13.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.35,90,,15.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.92,88,,15.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,19.35,
ACTIN ANTIBODY  (MAYO),1883512,CDM,300,RC,86255,HCPCS,Outpatient,,,21.5,12.9,,18.28,85,,14.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.21,80.03,,13.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.35,90,,15.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.92,88,,15.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,19.35,
"WHEAT ALLERGAN, IGE  (MAYO)",1886805,CDM,300,RC,86003,HCPCS,Outpatient,,,21.5,12.9,,18.28,85,,14.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.21,80.03,,13.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.35,90,,15.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.92,88,,15.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,19.35,
CHOCOLATE ALLERGAN IGE  (MAYO),1886806,CDM,300,RC,86003,HCPCS,Outpatient,,,21.5,12.9,,18.28,85,,14.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.21,80.03,,13.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.35,90,,15.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.92,88,,15.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,19.35,
SET SECONDARY IV 15 DROPS,492142,CDM,270,RC,,,Outpatient,,,21.53,12.92,,18.3,85,,14.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.92,32.15,,5.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.23,80.03,,13.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.38,90,,15.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.92,32.15,,5.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.53,,,,Other,Not Separately reimbursable,6.92,32.15,,5.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.95,88,,15.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.13,33.11,,5.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.92,19.38,
Test of body fluid other than blood to assess for bacteria,1884827,CDM,300,RC,87070,HCPCS,Outpatient,,,21.55,12.93,,18.32,85,,14.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.25,80.03,,13.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.4,90,,15.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.96,88,,15.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,19.4,
DOPAMINE : 200MG/5M INJ,293239,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
INDIGO CARMINE INJ,293242,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
POLY-VI-SOL W/FE 50ML,295603,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
POLY-VI-SOL,295611,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
WYDASE 15OU'S,296068,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
ISOPTO ATROPINE 1/2% O/S,297702,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
KWELL 1% (LINDANE) LOTION 60ML,298007,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
KENALOG SPRAY 23GM,298008,CDM,250,RC,,,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.63,,,,Other,Not Separately reimbursable,6.95,32.15,,5.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.16,33.11,,5.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.95,19.47,
DEPO-ESTRADIOL 5MG/1MLINJ,293060,CDM,636,RC,J1000,HCPCS,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.63,,,,Other,Not Separately reimbursable,32.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.31,32.67,
XYLOCAINE (LIDOCAINE) 1%: MDV 50ML,293217,CDM,636,RC,J2001,HCPCS,Outpatient,,,21.63,12.98,,18.39,85,,14.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.31,80.03,,13.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.47,90,,15.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.63,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.03,88,,15.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,19.47,
dsDNA AB REFLEX IGG (MAYO),1886226,CDM,300,RC,86225,HCPCS,Outpatient,,,21.67,13,,18.42,85,,14.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.34,80.03,,13.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.5,90,,15.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.07,88,,15.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.28,19.5,
LENS REMOVER HARD,496536,CDM,270,RC,,,Outpatient,,,21.75,13.05,,18.49,85,,14.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.99,32.15,,5.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.41,80.03,,13.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.58,90,,15.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.99,32.15,,5.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.75,,,,Other,Not Separately reimbursable,6.99,32.15,,5.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.14,88,,15.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.2,33.11,,5.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.99,19.58,
Collection of venous blood by venipuncture,9051,CDM,300,RC,36415,HCPCS,Outpatient,,,21.75,13.05,,18.49,85,,14.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.99,32.15,,5.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.41,80.03,,13.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,19.58,90,,15.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.99,32.15,,5.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.99,32.15,,5.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.14,88,,15.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.2,33.11,,5.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6.99,19.58,
MVI-12 (MULTIVITAMIN) 10ML,296042,CDM,250,RC,,,Outpatient,,,22,13.2,,18.7,85,,14.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.61,80.03,,14.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.8,90,,15.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,,,,Other,Not Separately reimbursable,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.36,88,,15.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.28,33.11,,5.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.07,19.8,
AMIDATE (etomidate) 40MG/20ML AMP,301304,CDM,250,RC,,,Outpatient,,,22,13.2,,18.7,85,,14.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.61,80.03,,14.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.8,90,,15.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,,,,Other,Not Separately reimbursable,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.36,88,,15.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.28,33.11,,5.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.07,19.8,
SCISSORS STRAIGHT 4-1/2  DISPOSABLE,4910094,CDM,270,RC,,,Outpatient,,,22,13.2,,18.7,85,,14.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.61,80.03,,14.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.8,90,,15.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,,,,Other,Not Separately reimbursable,7.07,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.36,88,,15.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.28,33.11,,5.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.07,19.8,
XYLOC2%  W/EPI (LIDO2/EPI200K); SDV 20ML,293306,CDM,250,RC,,,Outpatient,,,22.01,13.21,,18.71,85,,14.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.08,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.61,80.03,,14.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.81,90,,15.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.08,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.01,,,,Other,Not Separately reimbursable,7.08,32.15,,5.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.37,88,,15.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.29,33.11,,5.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.08,19.81,
CLEOCIN (CLINDAMYCIN) : 300MG VIAL,293043,CDM,250,RC,S0077,HCPCS,Outpatient,,,22.15,13.29,,18.83,85,,15.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.73,80.03,,14.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.94,90,,15.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.49,88,,15.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.33,33.11,,5.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.12,19.94,
CORTENEMA (HYDROCORTISONE) : 60ML,295506,CDM,250,RC,,,Outpatient,,,22.15,13.29,,18.83,85,,15.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.73,80.03,,14.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.94,90,,15.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.49,88,,15.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.33,33.11,,5.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.12,19.94,
VIOFORM HC CRM MILD 30GM,297061,CDM,250,RC,,,Outpatient,,,22.15,13.29,,18.83,85,,15.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.73,80.03,,14.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.94,90,,15.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.49,88,,15.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.33,33.11,,5.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.12,19.94,
KWELL 1% (LINDANE) SHAMPOO 60ML,298006,CDM,250,RC,,,Outpatient,,,22.15,13.29,,18.83,85,,15.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.73,80.03,,14.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.94,90,,15.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.49,88,,15.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.33,33.11,,5.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.12,19.94,
FLUSH- PREFILLED SOD CHLORIDE SYRINGE,293527,CDM,272,RC,A4218,HCPCS,Outpatient,,,22.15,13.29,,18.83,85,,15.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.73,80.03,,14.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.94,90,,15.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.12,32.15,,5.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.49,88,,15.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.33,33.11,,5.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.12,19.94,
TORADOL (KETOROLAC) : 30MG INJ,293418,CDM,636,RC,J1885,HCPCS,Outpatient,,,22.15,13.29,,18.83,85,,15.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.73,80.03,,14.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.94,90,,15.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.49,88,,15.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.61,19.94,
TORADOL (KETOROLAC) : 15MG INJ,293569,CDM,636,RC,J1885,HCPCS,Outpatient,,,22.15,13.29,,18.83,85,,15.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.73,80.03,,14.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.94,90,,15.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.49,88,,15.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.61,19.94,
NORTRIPTYLINE   (MAYO),1880182,CDM,300,RC,80335,HCPCS,Outpatient,,,22.25,13.35,,18.91,85,,15.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.81,80.03,,14.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.03,90,,16.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,22.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.58,88,,15.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.19,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.81,22.51,
Test to determine levels of immunoglobulins in the blood,1882058,CDM,300,RC,82784,HCPCS,Outpatient,,,22.25,13.35,,18.91,85,,15.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.81,80.03,,14.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.03,90,,16.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.58,88,,15.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.69,20.03,
"ALBUMIN, CSF  (MAYO)",1882059,CDM,300,RC,82042,HCPCS,Outpatient,,,22.25,13.35,,18.91,85,,15.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.81,80.03,,14.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.03,90,,16.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.58,88,,15.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,20.03,
PULSE OX CONTINUOUS,30385,CDM,460,RC,94762,HCPCS,Outpatient,,,22.25,13.35,,18.91,85,,15.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.15,32.15,,5.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.81,80.03,,14.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,20.03,90,,16.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.15,32.15,,5.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,7.15,32.15,,5.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.58,88,,15.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.37,33.11,,5.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.15,20.03,
CLAFORAN (cefotaxime) : 500MG VIAL,293446,CDM,636,RC,J0698,HCPCS,Outpatient,,,22.25,13.35,,18.91,85,,15.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.81,80.03,,14.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.03,90,,16.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.25,,,,Other,Not Separately reimbursable,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.58,88,,15.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.8,20.03,
SUBLIMAZE (fentanyl) 2ML AMP,299049,CDM,636,RC,J3010,HCPCS,Outpatient,,,22.3,13.38,,18.96,85,,15.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.85,80.03,,14.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.07,90,,16.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.3,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.62,88,,15.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,20.07,
CAFFEINE SODIUM BENZOATE 500MG/2ML INJ,293534,CDM,250,RC,,,Outpatient,,,22.5,13.5,,19.13,85,,15.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.23,32.15,,5.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.01,80.03,,14.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.25,90,,16.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.23,32.15,,5.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.5,,,,Other,Not Separately reimbursable,7.23,32.15,,5.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.8,88,,15.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.45,33.11,,5.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.23,20.25,
SCISSORS CURVED 4-1/2  DISPOSABLE,4910095,CDM,270,RC,,,Outpatient,,,22.5,13.5,,19.13,85,,15.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.23,32.15,,5.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.01,80.03,,14.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.25,90,,16.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.23,32.15,,5.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.5,,,,Other,Not Separately reimbursable,7.23,32.15,,5.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.8,88,,15.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.45,33.11,,5.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.23,20.25,
"PORPHYRINS, URINE QL  (MAYO)",1884119,CDM,300,RC,84119,HCPCS,Outpatient,,,22.5,13.5,,19.13,85,,15.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.01,80.03,,14.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.25,90,,16.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.8,88,,15.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,20.25,
PYRIDOXINE (VIT B-6) 100MG/ML 1ML INJ,293538,CDM,636,RC,J3420,HCPCS,Outpatient,,,22.5,13.5,,19.13,85,,15.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.01,80.03,,14.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.25,90,,16.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.5,,,,Other,Not Separately reimbursable,1.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.8,88,,15.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.33,20.25,
PILOCARPINE 1% OPTH SOLN: U/D,303955,CDM,250,RC,,,Outpatient,,,22.55,13.53,,19.17,85,,15.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.25,32.15,,5.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.05,80.03,,14.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.3,90,,16.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.25,32.15,,5.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.55,,,,Other,Not Separately reimbursable,7.25,32.15,,5.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.84,88,,15.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.47,33.11,,5.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.25,20.3,
LEVAQUIN (levofloxacin) 500MG TAB,29303,CDM,250,RC,,,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,,,,Other,Not Separately reimbursable,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,33.11,,6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.29,20.39,
SUPRAX 400MG TAB,29775,CDM,250,RC,,,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,,,,Other,Not Separately reimbursable,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,33.11,,6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.29,20.39,
AVELOX (moxifloxacin) 400mg TAB,29822,CDM,250,RC,,,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,,,,Other,Not Separately reimbursable,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,33.11,,6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.29,20.39,
LEVAQUIN (levofloxacin) 250MG TAB,29885,CDM,250,RC,,,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,,,,Other,Not Separately reimbursable,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,33.11,,6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.29,20.39,
ISUPREL (ISOPROTERENOL) INH SOLN,292036,CDM,250,RC,,,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,,,,Other,Not Separately reimbursable,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,33.11,,6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.29,20.39,
EURAX CREAM 60GM,297021,CDM,250,RC,,,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,,,,Other,Not Separately reimbursable,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,33.11,,6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.29,20.39,
VIOFORM OINTMENT 20GM,297059,CDM,250,RC,,,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,,,,Other,Not Separately reimbursable,7.29,32.15,,5.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,33.11,,6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.29,20.39,
DECADRON (DEXAMETHASONE) 10MG/ML INJ,293054,CDM,636,RC,J1100,HCPCS,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.66,,,,Other,Not Separately reimbursable,0.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.13,20.39,
XYLOC (LIDOCAINE) 1% :NERVEBLOCK MPF30ML,293215,CDM,636,RC,J2001,HCPCS,Outpatient,,,22.66,13.6,,19.26,85,,15.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.13,80.03,,14.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.39,90,,16.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.66,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.94,88,,15.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,20.39,
FIBROSURE GGT (MAYO),1883880,CDM,300,RC,82977,HCPCS,Outpatient,,,22.75,13.65,,19.34,85,,15.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.21,80.03,,14.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.48,90,,16.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.02,88,,16.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,20.48,
PREVACID (lansoprazole) SOLUTAB 30MG* NF,29685,CDM,250,RC,,,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23,,,,Other,Not Separately reimbursable,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.62,33.11,,6.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.39,20.7,
JANUVIA (sitagliptin)50MG TAB,29889,CDM,250,RC,,,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23,,,,Other,Not Separately reimbursable,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.62,33.11,,6.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.39,20.7,
CLORPACTIN WCS-90 2GM VIAL,296091,CDM,250,RC,,,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23,,,,Other,Not Separately reimbursable,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.62,33.11,,6.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.39,20.7,
SILVADENE (SILVER SULFADIAZINE) 50GM,297048,CDM,250,RC,,,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23,,,,Other,Not Separately reimbursable,7.39,32.15,,5.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.62,33.11,,6.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.39,20.7,
PNEUMO AB TYPE 1,1886620,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 3,1886621,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 4,1886622,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 8,1886623,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 9,1886624,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 12,1886625,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 14,1886626,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 19,1886627,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 23,1886629,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 26,1886630,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 51,1886631,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PNEUMO AB TYPE 56,1886633,CDM,300,RC,86317,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,20.7,
PROTAMINE SULFATE INJ,296067,CDM,636,RC,J2720,HCPCS,Outpatient,,,23,13.8,,19.55,85,,15.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,80.03,,14.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.7,90,,16.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23,,,,Other,Not Separately reimbursable,0.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.24,88,,16.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.79,20.7,
OMNICEF (cefdinir) 125MG/5ML SUSP *DOSE,295192,CDM,250,RC,,,Outpatient,,,23.05,13.83,,19.59,85,,15.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.41,32.15,,5.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.45,80.03,,14.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.75,90,,16.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.41,32.15,,5.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.05,,,,Other,Not Separately reimbursable,7.41,32.15,,5.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.28,88,,16.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.63,33.11,,6.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.41,20.75,
NEO SYNEPHRINE (phenyleph) 2.5% OPTH 2ML,297748,CDM,250,RC,,,Outpatient,,,23.05,13.83,,19.59,85,,15.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.41,32.15,,5.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.45,80.03,,14.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.75,90,,16.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.41,32.15,,5.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.05,,,,Other,Not Separately reimbursable,7.41,32.15,,5.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.28,88,,16.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.63,33.11,,6.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.41,20.75,
MISC DRUG 20,29904,CDM,250,RC,,,Outpatient,,,23.18,13.91,,19.7,85,,15.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.55,80.03,,14.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.86,90,,16.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.18,,,,Other,Not Separately reimbursable,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.4,88,,16.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.67,33.11,,6.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.45,20.86,
DAKINS SOLN 0.25% (HALF-STRENGTH),296532,CDM,250,RC,,,Outpatient,,,23.18,13.91,,19.7,85,,15.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.55,80.03,,14.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.86,90,,16.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.18,,,,Other,Not Separately reimbursable,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.4,88,,16.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.67,33.11,,6.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.45,20.86,
ISOPTO HOMATROPINE 5% O/S,297719,CDM,250,RC,,,Outpatient,,,23.18,13.91,,19.7,85,,15.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.55,80.03,,14.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.86,90,,16.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.18,,,,Other,Not Separately reimbursable,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.4,88,,16.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.67,33.11,,6.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.45,20.86,
HOMATROPINE 2% OPTH SOLN 5ML,297768,CDM,250,RC,,,Outpatient,,,23.18,13.91,,19.7,85,,15.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.55,80.03,,14.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.86,90,,16.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.18,,,,Other,Not Separately reimbursable,7.45,32.15,,5.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.4,88,,16.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.67,33.11,,6.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.45,20.86,
SCISSORS WIRE CUTTING,4910096,CDM,270,RC,,,Outpatient,,,23.25,13.95,,19.76,85,,15.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.47,32.15,,5.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.61,80.03,,14.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.93,90,,16.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.47,32.15,,5.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.25,,,,Other,Not Separately reimbursable,7.47,32.15,,5.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.46,88,,16.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.7,33.11,,6.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.47,20.93,
LAP PORT CLOSURE GUIDES 5MM & 10/12MM,4999915,CDM,270,RC,,,Outpatient,,,23.25,13.95,,19.76,85,,15.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.47,32.15,,5.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.61,80.03,,14.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.93,90,,16.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.47,32.15,,5.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.25,,,,Other,Not Separately reimbursable,7.47,32.15,,5.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.46,88,,16.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.7,33.11,,6.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.47,20.93,
PENICILLIN : 2 MILL. UNIT VIAL,293368,CDM,636,RC,J2510,HCPCS,Outpatient,,,23.3,13.98,,19.81,85,,15.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.49,32.15,,5.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.65,80.03,,14.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,20.97,90,,16.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.49,32.15,,5.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,7.49,32.15,,5.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.5,88,,16.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.71,33.11,,6.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.49,20.97,
GAUZE SPONGE 4X4 STERILE,493058,CDM,270,RC,,,Outpatient,,,23.37,14.02,,19.86,85,,15.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.51,32.15,,6.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.7,80.03,,14.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.03,90,,16.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.51,32.15,,6.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.37,,,,Other,Not Separately reimbursable,7.51,32.15,,6.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.57,88,,16.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.74,33.11,,6.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.51,21.03,
MAG SULFATE 1G/100ML D5W**,293895,CDM,636,RC,J3475,HCPCS,Outpatient,,,23.41,14.05,,19.9,85,,15.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.74,80.03,,14.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.07,90,,16.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.41,,,,Other,Not Separately reimbursable,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.6,88,,16.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.76,21.07,
XYLOCAINE URO-JET 2% (LIDOCAINE) 5ML,297098,CDM,250,RC,,,Outpatient,,,23.5,14.1,,19.98,85,,15.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.81,80.03,,15.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.15,90,,16.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.5,,,,Other,Not Separately reimbursable,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.68,88,,16.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,33.11,,6.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.56,21.15,
ACCUPAP DEVICE,30406,CDM,270,RC,,,Outpatient,,,23.5,14.1,,19.98,85,,15.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.81,80.03,,15.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.15,90,,16.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.5,,,,Other,Not Separately reimbursable,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.68,88,,16.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,33.11,,6.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.56,21.15,
CONNECTOR  Y  LARGE,49828,CDM,270,RC,,,Outpatient,,,23.5,14.1,,19.98,85,,15.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.81,80.03,,15.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.15,90,,16.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.5,,,,Other,Not Separately reimbursable,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.68,88,,16.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,33.11,,6.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.56,21.15,
HEPATITIS B VACC (PF-PED) 0.5ML,293257,CDM,636,RC,90744,HCPCS,Outpatient,,,23.5,14.1,,19.98,85,,15.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.81,80.03,,15.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.15,90,,16.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.56,32.15,,6.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.68,88,,16.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,33.11,,6.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.56,21.15,
"POTASSIUM, 24HR URINE  (MAYO)",1882193,CDM,300,RC,84133,HCPCS,Outpatient,,,23.6,14.16,,20.06,85,,16.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.89,80.03,,15.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,21.24,90,,16.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.77,88,,16.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.41,21.24,
MARCAINE/SENSORCAINE (BUPIV)0.5%*MDV*50M,292006,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
MARCAINE/SENSORCAINE (BUPIV)0.5% MPF30ML,292009,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
MARCAINE-SPINAL (BUPIVICAINE) 2ML AMP,292094,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
FER-IN-SOL 50ML ORAL,294019,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.69,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
SUSPHRINE 1:200 INJ,296052,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.69,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
ARISTOCORT A 0.1% 15GM,297006,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.69,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
HYTONE OINT 1% 30GM,297067,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.69,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
FLURESE OPTH SOL 5ML,297710,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.69,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
MARCAINE/SENSORCAINE (BUPIV)0.5% MPF10ML,300037,CDM,250,RC,,,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.69,,,,Other,Not Separately reimbursable,7.62,32.15,,6.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.84,33.11,,6.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.62,21.32,
SUBLIMAZE (fentanyl) 5ML AMP,299050,CDM,636,RC,J3010,HCPCS,Outpatient,,,23.69,14.21,,20.14,85,,16.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.96,80.03,,15.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.32,90,,17.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.69,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.85,88,,16.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,21.32,
DRESSING TENDERWET 2.2  RD PREWET,498035,CDM,272,RC,,,Outpatient,,,23.75,14.25,,20.19,85,,16.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.64,32.15,,6.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.01,80.03,,15.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.38,90,,17.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.64,32.15,,6.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.75,,,,Other,Not Separately reimbursable,7.64,32.15,,6.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.9,88,,16.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.86,33.11,,6.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.64,21.38,
Manual urinalysis test with examination with or without using microscope,1881004,CDM,300,RC,81001,HCPCS,Outpatient,,,23.78,14.27,,20.21,85,,16.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.03,80.03,,15.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.23,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,21.4,90,,17.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.23,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.93,88,,16.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.99,21.4,
"URIC ACID, BLOOD",1884550,CDM,300,RC,84550,HCPCS,Outpatient,,,23.78,14.27,,20.21,85,,16.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.03,80.03,,15.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,21.4,90,,17.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.93,88,,16.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.68,21.4,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,1887205,CDM,300,RC,87205,HCPCS,Outpatient,,,23.78,14.27,,20.21,85,,16.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.03,80.03,,15.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,21.4,90,,17.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.93,88,,16.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.95,21.4,
"Measles, mumps and rubella vaccine",296051,CDM,636,RC,90707,HCPCS,Outpatient,,,23.95,14.37,,20.36,85,,16.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.17,80.03,,15.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.56,90,,17.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.95,,,,Other,Not Separately reimbursable,89.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.08,88,,16.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.17,89.87,
ELIQUIS (apixaban) 2.5MG TAB,304587,CDM,250,RC,,,Outpatient,,,23.96,14.38,,20.37,85,,16.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.7,32.15,,6.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.18,80.03,,15.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.56,90,,17.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.7,32.15,,6.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.96,,,,Other,Not Separately reimbursable,7.7,32.15,,6.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.08,88,,16.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.93,33.11,,6.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.7,21.56,
LASIX (furosemide) :100MG/10ML INJ,293097,CDM,636,RC,J1940,HCPCS,Outpatient,,,24,14.4,,20.4,85,,16.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.21,80.03,,15.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.6,90,,17.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24,,,,Other,Not Separately reimbursable,0.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.12,88,,16.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.58,21.6,
ACTIQ LOZ. (fentanyl) 200MCG,299071,CDM,636,RC,J3010,HCPCS,Outpatient,,,24,14.4,,20.4,85,,16.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.21,80.03,,15.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.6,90,,17.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.12,88,,16.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,21.6,
FLAGYL (metronidazole) 750MG ER TAB,291057,CDM,250,RC,,,Outpatient,,,24.1,14.46,,20.49,85,,16.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.75,32.15,,6.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.29,80.03,,15.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.69,90,,17.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.75,32.15,,6.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.1,,,,Other,Not Separately reimbursable,7.75,32.15,,6.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.21,88,,16.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.98,33.11,,6.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.75,21.69,
STADOL (butorphanol) 2MG/ML INJ,293173,CDM,636,RC,J0595,HCPCS,Outpatient,,,24.1,14.46,,20.49,85,,16.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.29,80.03,,15.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.69,90,,17.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.1,,,,Other,Not Separately reimbursable,2.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.21,88,,16.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.62,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.54,21.69,
MARCAINE 0.25% W/EPI (BUPIV/EPI)MPF;30ML,293186,CDM,250,RC,,,Outpatient,,,24.16,14.5,,20.54,85,,16.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.77,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.34,80.03,,15.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.74,90,,17.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.77,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.16,,,,Other,Not Separately reimbursable,7.77,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.26,88,,17.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8,33.11,,6.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.77,21.74,
SULTRIN VAG CRM,292019,CDM,250,RC,,,Outpatient,,,24.21,14.53,,20.58,85,,16.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.38,80.03,,15.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.79,90,,17.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.21,,,,Other,Not Separately reimbursable,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.3,88,,17.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.02,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.78,21.79,
"EPINEPHRINE 1:10,000 ABJ 10ML/18G",293078,CDM,250,RC,,,Outpatient,,,24.21,14.53,,20.58,85,,16.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.38,80.03,,15.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.79,90,,17.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.21,,,,Other,Not Separately reimbursable,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.3,88,,17.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.02,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.78,21.79,
POLY-VI-FLOR : 50ML,294029,CDM,250,RC,,,Outpatient,,,24.21,14.53,,20.58,85,,16.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.38,80.03,,15.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.79,90,,17.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.21,,,,Other,Not Separately reimbursable,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.3,88,,17.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.02,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.78,21.79,
POLY-VI-FLOR WITH FE : 50ML,294043,CDM,250,RC,,,Outpatient,,,24.21,14.53,,20.58,85,,16.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.38,80.03,,15.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.79,90,,17.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.21,,,,Other,Not Separately reimbursable,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.3,88,,17.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.02,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.78,21.79,
EPPY-N 1% 7.5ML,297761,CDM,250,RC,,,Outpatient,,,24.21,14.53,,20.58,85,,16.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.38,80.03,,15.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.79,90,,17.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.21,,,,Other,Not Separately reimbursable,7.78,32.15,,6.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.3,88,,17.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.02,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.78,21.79,
DEPO-TESTOSTERONE 200MG 1ML,293089,CDM,636,RC,J1071,HCPCS,Outpatient,,,24.21,14.53,,20.58,85,,16.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.38,80.03,,15.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.79,90,,17.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.21,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.3,88,,17.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,21.79,
TORADOL (KETOROLAC): 60MG INJ,293419,CDM,636,RC,J1885,HCPCS,Outpatient,,,24.21,14.53,,20.58,85,,16.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.38,80.03,,15.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.79,90,,17.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.21,,,,Other,Not Separately reimbursable,0.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.3,88,,17.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.61,21.79,
EUCERIN 2 OZ,297082,CDM,250,RC,,,Outpatient,,,24.25,14.55,,20.61,85,,16.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.41,80.03,,15.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.83,90,,17.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,,,,Other,Not Separately reimbursable,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.34,88,,17.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.03,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.8,21.83,
CATH ULTRAMER 14FR URETHRAL RED RUBBER,49618,CDM,270,RC,,,Outpatient,,,24.25,14.55,,20.61,85,,16.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.41,80.03,,15.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.83,90,,17.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,,,,Other,Not Separately reimbursable,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.34,88,,17.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.03,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.8,21.83,
SPLINT FINGER 1/2 X 18,49701,CDM,270,RC,,,Outpatient,,,24.25,14.55,,20.61,85,,16.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.41,80.03,,15.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.83,90,,17.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,,,,Other,Not Separately reimbursable,7.8,32.15,,6.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.34,88,,17.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.03,33.11,,6.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.8,21.83,
"ZINC, SERUM  (MAYO)",1884630,CDM,300,RC,84630,HCPCS,Outpatient,,,24.25,14.55,,20.61,85,,16.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.41,80.03,,15.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,21.83,90,,17.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.34,88,,17.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.32,21.83,
DEPACON (valproic acid) 500MG/5ML INJ,293530,CDM,250,RC,,,Outpatient,,,24.3,14.58,,20.66,85,,16.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.81,32.15,,6.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.45,80.03,,15.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.87,90,,17.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.81,32.15,,6.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.3,,,,Other,Not Separately reimbursable,7.81,32.15,,6.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.38,88,,17.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.05,33.11,,6.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.81,21.87,
ALFENTA (alfentanil) 500mcg/ml AMP,299072,CDM,250,RC,,,Outpatient,,,24.35,14.61,,20.7,85,,16.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.83,32.15,,6.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.49,80.03,,15.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.92,90,,17.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.83,32.15,,6.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.35,,,,Other,Not Separately reimbursable,7.83,32.15,,6.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.43,88,,17.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.06,33.11,,6.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.83,21.92,
FOSAMAX (ALENDRONATE) 35MG TAB,29874,CDM,250,RC,,,Outpatient,,,24.5,14.7,,20.83,85,,16.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.61,80.03,,15.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.05,90,,17.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.5,,,,Other,Not Separately reimbursable,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.56,88,,17.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.11,33.11,,6.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.88,22.05,
DURAGESIC (fentanyl) 12 mcg PATCH,292132,CDM,250,RC,,,Outpatient,,,24.5,14.7,,20.83,85,,16.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.61,80.03,,15.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.05,90,,17.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.5,,,,Other,Not Separately reimbursable,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.56,88,,17.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.11,33.11,,6.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.88,22.05,
GROWTH HORMONE  (MAYO),1883003,CDM,300,RC,83003,HCPCS,Outpatient,,,24.5,14.7,,20.83,85,,16.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.61,80.03,,15.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.05,90,,17.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.56,88,,17.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.9,22.05,
AHG CROSSMATCH (PER UNIT),1887804,CDM,300,RC,86922,HCPCS,Outpatient,,,24.5,14.7,,20.83,85,,16.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.61,80.03,,15.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,22.05,90,,17.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,7.88,32.15,,6.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.56,88,,17.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.11,33.11,,6.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.88,22.05,
ALBUMIN,1882040,CDM,300,RC,82040,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.62,22.14,
Measurement of direct bilirubin,1882251,CDM,300,RC,82248,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,22.14,
Blood test to detect heart enzymes,1882552,CDM,300,RC,82553,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.52,22.14,
CPK,1882555,CDM,300,RC,82550,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.64,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.64,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,22.14,
"CREATININE, SERUM",1882565,CDM,300,RC,82565,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,22.14,
Test to measure creatinine in the urine,1882580,CDM,300,RC,82570,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,22.14,
"PHOSPHORUS, BLOOD",1884100,CDM,300,RC,84100,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.97,22.14,
Blood test to evaluate liver function,1884465,CDM,300,RC,84460,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,22.14,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,1887146,CDM,300,RC,87046,HCPCS,Outpatient,,,24.6,14.76,,20.91,85,,16.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,80.03,,15.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.14,90,,17.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,88,,17.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.97,22.14,
DAKINS SOLN 0.5% (FULL STRENGTH),296531,CDM,250,RC,,,Outpatient,,,24.72,14.83,,21.01,85,,16.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.78,80.03,,15.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.25,90,,17.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.72,,,,Other,Not Separately reimbursable,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.75,88,,17.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.18,33.11,,6.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.95,22.25,
DAKINS SOLN 0.125% (QUARTER-STRENGTH),296536,CDM,250,RC,,,Outpatient,,,24.72,14.83,,21.01,85,,16.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.78,80.03,,15.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.25,90,,17.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.72,,,,Other,Not Separately reimbursable,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.75,88,,17.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.18,33.11,,6.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.95,22.25,
ELAVIL (AMITRIPTYLINE) 10MG/ML: 10MLINJ,293075,CDM,636,RC,J1320,HCPCS,Outpatient,,,24.72,14.83,,21.01,85,,16.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.78,80.03,,15.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.25,90,,17.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.72,,,,Other,Not Separately reimbursable,7.95,32.15,,6.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.75,88,,17.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.18,33.11,,6.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.95,22.25,
"BICILLIN LA : 600,000",296012,CDM,636,RC,J0561,HCPCS,Outpatient,,,24.72,14.83,,21.01,85,,16.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.78,80.03,,15.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.56,102,,,fee schedule,Pays at 102% of CMS APC rate,22.25,90,,17.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.56,100,,,fee schedule,Pays at 100% of CMS APC rate,20.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.75,88,,17.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.78,22.25,
Automated urinalysis test,1881003,CDM,300,RC,81003,HCPCS,Outpatient,,,24.75,14.85,,21.04,85,,16.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.81,80.03,,15.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.28,90,,17.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.78,88,,17.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.83,22.28,
ZITHROMAX (azith)100MG/5ML  (ER DOSE),298068,CDM,250,RC,,,Outpatient,,,24.85,14.91,,21.12,85,,16.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.99,32.15,,6.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.89,80.03,,15.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.37,90,,17.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.99,32.15,,6.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.85,,,,Other,Not Separately reimbursable,7.99,32.15,,6.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.87,88,,17.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.23,33.11,,6.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7.99,22.37,
Flu shot-high dose for 2019-2020 flu season given by injection,293276,CDM,636,RC,90656,HCPCS,Outpatient,,,24.99,14.99,,21.24,85,,16.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.03,32.15,,6.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20,80.03,,16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.49,90,,17.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.03,32.15,,6.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.03,32.15,,6.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.99,88,,17.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.27,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.03,22.49,
DIFLUCAN (fluconazole) 100MG TAB,29174,CDM,250,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
LEVOPHED (norepinephrine) 4MG/4ML INJ,293098,CDM,250,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
ZANTAC (ranitidine) : 50MG VIAL,293391,CDM,250,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
XOPENEX (levalbuterol)1.25MG/0.5ML SOL**,300458,CDM,250,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
PULMONARY COMPLIANCE,30014,CDM,270,RC,94750,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
BILI LIGHT,30070,CDM,270,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
INSPIREASE REPLACEMENT BAG,30200,CDM,270,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
CPM RENT,31202,CDM,270,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
CATH IV INTROCAN 20G x 1 1/4,496308,CDM,270,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
MANUAL TRACTION(INACTIVE),3197122,CDM,270,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
KINETIC ADD 15 MIN(INACTIVE),3197531,CDM,270,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
..TEST ANCA,919191,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST PHENYTOIN FREE AND TOTAL,919192,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST HEMOCHROMATOSIS HFE,919193,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST ACE,919194,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST 25 HYDROXY D2 AND D3,919195,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST ENDOMYSIAL ABS,919196,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST HER2 QUANT,919197,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST IHC AUTOMATED,919198,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
..TEST MISC1,919199,CDM,300,RC,82164,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,22.5,
Obstetric blood test panel,1880055,CDM,300,RC,80055,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.01,28.08,
RESERVED (MAYO),1886809,CDM,300,RC,86638,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.36,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.36,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.25,22.5,
RESERVED (MAYO),1886811,CDM,300,RC,86638,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.36,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.36,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.25,22.5,
RESERVED (MAYO),1886814,CDM,300,RC,86638,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.36,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.36,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.25,22.5,
A technique used by physical therapists to restore normal body movement patterns,5997531,CDM,430,RC,97112,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
Therapy for speech or hearing,31137,CDM,440,RC,92507,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
60 GTT TUBING,496528,CDM,540,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
VANCOCIN (vancomycin): 500MG VIAL,293389,CDM,636,RC,J3370,HCPCS,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,22.5,
CARDIAC REHAB MAINTENANCE TRAINING,4000,CDM,943,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
TRAY IRRIGATION W/SYRINGE,492034,CDM,270,RC,,,Outpatient,,,25.01,15.01,,21.26,85,,17.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.02,80.03,,16.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.51,90,,18.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.01,88,,17.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.51,
"SODIUM, 24HR URINE  (MAYO)",1882192,CDM,300,RC,84300,HCPCS,Outpatient,,,25.2,15.12,,21.42,85,,17.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.17,80.03,,16.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,22.68,90,,18.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.18,88,,17.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.35,22.68,
OINTMENT ANTIFUNGAL 2-N-1,491514,CDM,270,RC,,,Outpatient,,,25.25,15.15,,21.46,85,,17.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.12,32.15,,6.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.21,80.03,,16.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.73,90,,18.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.12,32.15,,6.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.12,32.15,,6.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.22,88,,17.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.36,33.11,,6.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.12,22.73,
PRED FORTE (PREDNISOLONE) 1% OPTH: U/D,303951,CDM,250,RC,,,Outpatient,,,25.34,15.2,,21.54,85,,17.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.15,32.15,,6.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.28,80.03,,16.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.81,90,,18.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.15,32.15,,6.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.15,32.15,,6.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.3,88,,17.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.39,33.11,,6.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.15,22.81,
AZA SITE (azithromycin) OPTH SOLN (UD),297525,CDM,250,RC,,,Outpatient,,,25.4,15.24,,21.59,85,,17.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.17,32.15,,6.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.33,80.03,,16.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.86,90,,18.29,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.17,32.15,,6.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.17,32.15,,6.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.35,88,,17.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.41,33.11,,6.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.17,22.86,
FELBATOL (FELBAMATE) 600MG/5ML SUSP: 1OZ,292309,CDM,250,RC,,,Outpatient,,,25.5,15.3,,21.68,85,,17.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.41,80.03,,16.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,90,,18.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.44,88,,17.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.44,33.11,,6.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.2,22.95,
UNIPEN  (nafcillin) 500MG /NS 25ML PB,293199,CDM,250,RC,,,Outpatient,,,25.5,15.3,,21.68,85,,17.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.41,80.03,,16.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,90,,18.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.44,88,,17.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.44,33.11,,6.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.2,22.95,
WESTCORT (hydrocort val) 0.2% OINT 45GM,297005,CDM,250,RC,,,Outpatient,,,25.5,15.3,,21.68,85,,17.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.41,80.03,,16.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,90,,18.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.44,88,,17.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.44,33.11,,6.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.2,22.95,
ISOPTO CARPINE 1% O/S,297715,CDM,250,RC,,,Outpatient,,,25.5,15.3,,21.68,85,,17.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.41,80.03,,16.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,90,,18.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.44,88,,17.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.44,33.11,,6.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.2,22.95,
EPPY N 2% O/S,297753,CDM,250,RC,,,Outpatient,,,25.5,15.3,,21.68,85,,17.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.41,80.03,,16.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,90,,18.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.44,88,,17.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.44,33.11,,6.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.2,22.95,
BOTTLE PERITONEAL IRRIGATION,49264,CDM,270,RC,,,Outpatient,,,25.5,15.3,,21.68,85,,17.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.41,80.03,,16.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,90,,18.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.44,88,,17.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.44,33.11,,6.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.2,22.95,
LIBRIUM (CHLORDIAZEPOXIDE) 100MG INJ,296036,CDM,636,RC,J1990,HCPCS,Outpatient,,,25.5,15.3,,21.68,85,,17.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.41,80.03,,16.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,90,,18.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.2,32.15,,6.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.44,88,,17.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.44,33.11,,6.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.2,22.95,
MYDRIACYL (TROPICAMIDE) 1% OPTH SOLN,297723,CDM,250,RC,,,Outpatient,,,25.56,15.34,,21.73,85,,17.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.22,32.15,,6.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.46,80.03,,16.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,90,,18.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.22,32.15,,6.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.22,32.15,,6.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.49,88,,17.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.46,33.11,,6.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.22,23,
APLISOL PPD 0.1ML,296073,CDM,250,RC,,,Outpatient,,,25.58,15.35,,21.74,85,,17.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.22,32.15,,6.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.47,80.03,,16.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.02,90,,18.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.22,32.15,,6.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.22,32.15,,6.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.51,88,,18.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.47,33.11,,6.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.22,23.02,
PROTECTOR EYE PREMATURE PHOTO THERAPY,497756,CDM,270,RC,,,Outpatient,,,25.75,15.45,,21.89,85,,17.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.61,80.03,,16.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,90,,18.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,88,,18.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.53,33.11,,6.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.28,23.18,
PROTECTOR EYE NEWBORN PHOTO THERAPY,497766,CDM,270,RC,,,Outpatient,,,25.75,15.45,,21.89,85,,17.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.61,80.03,,16.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,90,,18.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,88,,18.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.53,33.11,,6.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.28,23.18,
BOUGIE COPILOT 60CM ADULT ENDO TUBE INTR,4985870,CDM,270,RC,,,Outpatient,,,25.75,15.45,,21.89,85,,17.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.61,80.03,,16.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,90,,18.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.28,32.15,,6.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.66,88,,18.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.53,33.11,,6.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.28,23.18,
ANA COMP PROFILE  (MAYO),1886037,CDM,300,RC,86038,HCPCS,Outpatient,,,25.9,15.54,,22.02,85,,17.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.73,80.03,,16.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.31,90,,18.65,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.79,88,,18.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.2,23.31,
MARKER SKIN WITH RULER,493024,CDM,270,RC,,,Outpatient,,,25.94,15.56,,22.05,85,,17.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.34,32.15,,6.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.76,80.03,,16.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.35,90,,18.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.34,32.15,,6.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.34,32.15,,6.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.83,88,,18.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.59,33.11,,6.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.34,23.35,
STERI-STRIPS 1/2 X 4,493316,CDM,270,RC,,,Outpatient,,,25.94,15.56,,22.05,85,,17.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.34,32.15,,6.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.76,80.03,,16.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.35,90,,18.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.34,32.15,,6.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.34,32.15,,6.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.83,88,,18.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.59,33.11,,6.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.34,23.35,
ZANTAC (ranitidine) 15MG/ML SOLN: 1OZ,292305,CDM,250,RC,,,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.4,
NOZIN PREOP NASAL SWAB (1 BOX/3 SWABS),300230,CDM,250,RC,,,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.4,
GASTROGRAFIN 30ML BTL,225037,CDM,255,RC,,,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.4,
DRESSING CUTIMED SILTEC SORBACT 3X3,49292,CDM,270,RC,,,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.4,
TRACTION FOAM BUCKS MEDIUM,492000,CDM,270,RC,,,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.4,
"CHLORIDE, 24HR URINE  (MAYO)",1882196,CDM,300,RC,82436,HCPCS,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,23.4,
Testing for presence of drug,1882771,CDM,300,RC,80307,HCPCS,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.81,61.16,
IGG1 SUBCLASS  (MAYO),1882805,CDM,300,RC,82787,HCPCS,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.08,23.4,
IGG2 SUBCLASS  (MAYO),1882806,CDM,300,RC,82787,HCPCS,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.08,23.4,
IGG3 SUBCLASS  (MAYO),1882807,CDM,300,RC,82787,HCPCS,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.08,23.4,
IGG4 SUBCLASS  (MAYO),1882808,CDM,300,RC,82787,HCPCS,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.08,23.4,
"COMPLEMENT AG, EACH  (MAYO)",1886326,CDM,300,RC,86160,HCPCS,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,23.4,
EMPLOYEE EXPRESS,14024,CDM,450,RC,,,Outpatient,,,26,15.6,,22.1,85,,17.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.81,80.03,,16.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.4,90,,18.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,88,,18.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.4,
MARCAINE/SENSORCAINE 0.5% W/EPI-MDV 50ML,292008,CDM,250,RC,,,Outpatient,,,26.01,15.61,,22.11,85,,17.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.82,80.03,,16.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.41,90,,18.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.89,88,,18.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.41,
ISOPTO CARPINE 2% O/S,297716,CDM,250,RC,,,Outpatient,,,26.01,15.61,,22.11,85,,17.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.82,80.03,,16.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.41,90,,18.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.36,32.15,,6.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.89,88,,18.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.61,33.11,,6.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.36,23.41,
XYLOCAINE (LIDOCAINE) 1% 10MG/ML:MPF30ML,293213,CDM,636,RC,J2001,HCPCS,Outpatient,,,26.01,15.61,,22.11,85,,17.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.82,80.03,,16.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.41,90,,18.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.89,88,,18.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,23.41,
XYLOCAINE (LIDOCAINE) 0.5% MPF 50ML,293216,CDM,636,RC,J2001,HCPCS,Outpatient,,,26.01,15.61,,22.11,85,,17.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.82,80.03,,16.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.41,90,,18.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.89,88,,18.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,23.41,
CANNULA VACURETTE CURVED 14MM BERKELEY,491809,CDM,270,RC,,,Outpatient,,,26.25,15.75,,22.31,85,,17.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.44,32.15,,6.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.01,80.03,,16.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.63,90,,18.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.44,32.15,,6.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.44,32.15,,6.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.1,88,,18.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.69,33.11,,6.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.44,23.63,
DRESSING QUICK 4.25  X 4,498034,CDM,272,RC,,,Outpatient,,,26.25,15.75,,22.31,85,,17.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.44,32.15,,6.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.01,80.03,,16.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.63,90,,18.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.44,32.15,,6.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.44,32.15,,6.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.1,88,,18.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.69,33.11,,6.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.44,23.63,
JANUVIA (sitagliptin) 100MG TAB,29890,CDM,250,RC,,,Outpatient,,,26.3,15.78,,22.36,85,,17.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.46,32.15,,6.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.05,80.03,,16.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.67,90,,18.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.46,32.15,,6.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.46,32.15,,6.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.14,88,,18.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.71,33.11,,6.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.46,23.67,
WOUND MANAGEMENT I,3921,CDM,490,RC,11040,HCPCS,Outpatient,,,26.3,15.78,,22.36,85,,17.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.46,32.15,,6.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.05,80.03,,16.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.67,90,,18.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.46,32.15,,6.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.46,32.15,,6.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.14,88,,18.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.71,33.11,,6.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.46,23.67,
..URINALYSIS-MICRO,1881015,CDM,300,RC,81015,HCPCS,Outpatient,,,26.4,15.84,,22.44,85,,17.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.13,80.03,,16.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.11,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.76,90,,19.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.11,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.23,88,,18.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.82,23.76,
NOZIN ANTISEPTIC BLISTERED PACK,4910001,CDM,270,RC,,,Outpatient,,,26.44,15.86,,22.47,85,,17.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.5,32.15,,6.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.16,80.03,,16.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.8,90,,19.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.5,32.15,,6.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.5,32.15,,6.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.27,88,,18.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.75,33.11,,7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.5,23.8,
KIRBY BAUER SENSITIVITY,1887184,CDM,300,RC,87184,HCPCS,Outpatient,,,26.5,15.9,,22.53,85,,18.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.21,80.03,,16.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,23.85,90,,19.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.32,88,,18.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.67,23.85,
DURAGESIC (fentanyl) 25mcg PATCH,292061,CDM,250,RC,,,Outpatient,,,26.53,15.92,,22.55,85,,18.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.23,80.03,,16.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.88,90,,19.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.35,88,,18.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.78,33.11,,7.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.53,23.88,
ALCOHOL DEHYDRATED : 1ML AMP,293004,CDM,250,RC,,,Outpatient,,,26.53,15.92,,22.55,85,,18.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.23,80.03,,16.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.88,90,,19.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.35,88,,18.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.78,33.11,,7.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.53,23.88,
MYLICON (SIMETHICONE) DROPS 30ML,294023,CDM,250,RC,,,Outpatient,,,26.53,15.92,,22.55,85,,18.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.23,80.03,,16.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.88,90,,19.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.35,88,,18.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.78,33.11,,7.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.53,23.88,
SODIUM BICARB (PED) 5MEQ/10ML ABBJ,295508,CDM,250,RC,,,Outpatient,,,26.53,15.92,,22.55,85,,18.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.23,80.03,,16.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.88,90,,19.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.35,88,,18.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.78,33.11,,7.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.53,23.88,
VIOFORM HC CREAM 20GM,297060,CDM,250,RC,,,Outpatient,,,26.53,15.92,,22.55,85,,18.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.23,80.03,,16.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.88,90,,19.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.53,32.15,,6.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.35,88,,18.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.78,33.11,,7.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.53,23.88,
XYLOC1% W/EPI (LIDO1/EPI100K) MDV:50ML,293219,CDM,636,RC,J2001,HCPCS,Outpatient,,,26.53,15.92,,22.55,85,,18.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.23,80.03,,16.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.88,90,,19.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.35,88,,18.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,23.88,
XYLOCAINE 2% W/EPI( LIDO W/EPI) MDV:50ML,293220,CDM,636,RC,J2001,HCPCS,Outpatient,,,26.53,15.92,,22.55,85,,18.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.23,80.03,,16.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.88,90,,19.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.35,88,,18.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,23.88,
ABILIFY (aripiprazole) 10MG TAB,29687,CDM,250,RC,,,Outpatient,,,26.65,15.99,,22.65,85,,18.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.57,32.15,,6.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.33,80.03,,17.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.99,90,,19.19,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.57,32.15,,6.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.57,32.15,,6.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.45,88,,18.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.82,33.11,,7.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.57,23.99,
FACE MASK DISP,13080,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TEMP PROBE SKIN,13085,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TEMP PROBE RECTAL,13090,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
CLOSURE TAIL SURE-FIT,491570,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TUBE TRACH ORAL RAE CUFFED 7.0,493790,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TUBE INFANT FEEDING 5FR,493792,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TUBE TRACH ORAL RAE CUFFED 8.0,493793,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TUBE TRACH ORAL RAE CUFFED 6.0,493800,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TUBE TRACH ORAL RAE CUFFED 6.5,493801,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
TUBE TRACH ORAL RAE CUFFED 7.5,493802,CDM,270,RC,,,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.6,32.15,,6.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.86,33.11,,7.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.6,24.08,
"VALPROIC ACID, FREE SERUM  (MAYO)",1882691,CDM,300,RC,80165,HCPCS,Outpatient,,,26.75,16.05,,22.74,85,,18.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.41,80.03,,17.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.08,90,,19.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.54,88,,18.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.36,24.08,
ZYPREXA (olanzapine) 2.5MG TAB,304843,CDM,250,RC,,,Outpatient,,,26.87,16.12,,22.84,85,,18.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.64,32.15,,6.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.5,80.03,,17.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.18,90,,19.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.64,32.15,,6.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.64,32.15,,6.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.65,88,,18.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.9,33.11,,7.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.64,24.18,
LIDODERM (lidocaine) PATCH 5%,291062,CDM,250,RC,,,Outpatient,,,27,16.2,,22.95,85,,18.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.61,80.03,,17.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.3,90,,19.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.76,88,,19.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.94,33.11,,7.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.68,24.3,
VANCOMYCIN 100MG - DIALYSIS,293428,CDM,250,RC,,,Outpatient,,,27,16.2,,22.95,85,,18.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.61,80.03,,17.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.3,90,,19.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27,,,,Other,Not Separately reimbursable,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.76,88,,19.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.94,33.11,,7.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.68,24.3,
NEOSPORIN GU (BACI/NEO/POLYMIX) IRRIGANT,296039,CDM,250,RC,,,Outpatient,,,27,16.2,,22.95,85,,18.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.61,80.03,,17.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.3,90,,19.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27,,,,Other,Not Separately reimbursable,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.76,88,,19.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.94,33.11,,7.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.68,24.3,
NEO SYNEPHRINE (phenyleph) 2.5% OPTH:U/D,303956,CDM,250,RC,,,Outpatient,,,27,16.2,,22.95,85,,18.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.61,80.03,,17.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.3,90,,19.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27,,,,Other,Not Separately reimbursable,8.68,32.15,,6.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.76,88,,19.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.94,33.11,,7.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.68,24.3,
OSMOLALITY SERUM  (MAYO),1883930,CDM,300,RC,83930,HCPCS,Outpatient,,,27,16.2,,22.95,85,,18.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.61,80.03,,17.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.3,90,,19.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.76,88,,19.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.32,24.3,
C1-ESTERASE INIHIBTOR  (MAYO),1886160,CDM,300,RC,86160,HCPCS,Outpatient,,,27,16.2,,22.95,85,,18.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.61,80.03,,17.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.3,90,,19.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.76,88,,19.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,24.3,
BSS 15 ML,292080,CDM,250,RC,,,Outpatient,,,27.04,16.22,,22.98,85,,18.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.64,80.03,,17.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.34,90,,19.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.04,,,,Other,Not Separately reimbursable,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.8,88,,19.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.95,33.11,,7.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.69,24.34,
SSKI  (potassium iodide) : 1OZ,292284,CDM,250,RC,,,Outpatient,,,27.04,16.22,,22.98,85,,18.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.64,80.03,,17.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.34,90,,19.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.04,,,,Other,Not Separately reimbursable,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.8,88,,19.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.95,33.11,,7.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.69,24.34,
ACTIV CHARCOAL W/SOR : 50MG/240,295501,CDM,250,RC,,,Outpatient,,,27.04,16.22,,22.98,85,,18.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.64,80.03,,17.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.34,90,,19.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.04,,,,Other,Not Separately reimbursable,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.8,88,,19.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.95,33.11,,7.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.69,24.34,
TOPICORT LP CREAM 0.05% 15G,297056,CDM,250,RC,,,Outpatient,,,27.04,16.22,,22.98,85,,18.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.64,80.03,,17.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.34,90,,19.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.04,,,,Other,Not Separately reimbursable,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.8,88,,19.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.95,33.11,,7.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.69,24.34,
PONTOCAINE 0.5% OPTH OINT,297512,CDM,250,RC,,,Outpatient,,,27.04,16.22,,22.98,85,,18.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.64,80.03,,17.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.34,90,,19.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.04,,,,Other,Not Separately reimbursable,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.8,88,,19.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.95,33.11,,7.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.69,24.34,
DEPO-MEDROL (METHYPREDNISOLONE) 80MG INJ,293062,CDM,636,RC,J1040,HCPCS,Outpatient,,,27.04,16.22,,22.98,85,,18.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.64,80.03,,17.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.34,90,,19.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.04,,,,Other,Not Separately reimbursable,10.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.8,88,,19.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.76,24.34,
STILPHOSTROL INJ,296253,CDM,636,RC,J9165,HCPCS,Outpatient,,,27.04,16.22,,22.98,85,,18.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.64,80.03,,17.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.34,90,,19.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.04,,,,Other,Not Separately reimbursable,8.69,32.15,,6.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.8,88,,19.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.95,33.11,,7.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.69,24.34,
CLAMP CORD,490807,CDM,270,RC,,,Outpatient,,,27.19,16.31,,23.11,85,,18.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.74,32.15,,6.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.76,80.03,,17.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.47,90,,19.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.74,32.15,,6.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.19,,,,Other,Not Separately reimbursable,8.74,32.15,,6.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.93,88,,19.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9,33.11,,7.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.74,24.47,
BIOSHIELD IRRIGATOR,492180,CDM,270,RC,,,Outpatient,,,27.25,16.35,,23.16,85,,18.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.76,32.15,,7.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.81,80.03,,17.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.53,90,,19.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.76,32.15,,7.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.25,,,,Other,Not Separately reimbursable,8.76,32.15,,7.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.98,88,,19.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.02,33.11,,7.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.76,24.53,
BIOSHIELD EXTENSION TUBING,492181,CDM,270,RC,,,Outpatient,,,27.25,16.35,,23.16,85,,18.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.76,32.15,,7.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.81,80.03,,17.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.53,90,,19.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.76,32.15,,7.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.25,,,,Other,Not Separately reimbursable,8.76,32.15,,7.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.98,88,,19.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.02,33.11,,7.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.76,24.53,
Test to measure creatinine in the urine,1882203,CDM,300,RC,82570,HCPCS,Outpatient,,,27.25,16.35,,23.16,85,,18.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.81,80.03,,17.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.53,90,,19.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.98,88,,19.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,24.53,
APRESOLINE(hyDRALazine) 20MG/1ML INJ,293012,CDM,636,RC,J0360,HCPCS,Outpatient,,,27.25,16.35,,23.16,85,,18.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.81,80.03,,17.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.53,90,,19.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.25,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.98,88,,19.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.76,24.53,
XYLOCAINE 5%/DEXTROSE 7.5% 2ML SPINAL,293472,CDM,636,RC,J2001,HCPCS,Outpatient,,,27.33,16.4,,23.23,85,,18.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.87,80.03,,17.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.6,90,,19.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.33,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.05,88,,19.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,24.6,
CALCIUM GLUCONATE 10%: 10ML VIAL,293031,CDM,636,RC,J0610,HCPCS,Outpatient,,,27.45,16.47,,23.33,85,,18.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.83,32.15,,7.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.97,80.03,,17.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.71,90,,19.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.83,32.15,,7.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.83,32.15,,7.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.16,88,,19.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.09,33.11,,7.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.83,24.71,
DOME-PASTE (UNNA'S BOOT) BANDAGE,297093,CDM,250,RC,,,Outpatient,,,27.5,16.5,,23.38,85,,18.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.01,80.03,,17.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,90,,19.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.2,88,,19.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.11,33.11,,7.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.84,24.75,
ROLZ SCAR MASSAGER,424,CDM,270,RC,,,Outpatient,,,27.5,16.5,,23.38,85,,18.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.01,80.03,,17.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,90,,19.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.2,88,,19.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.11,33.11,,7.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.84,24.75,
DRESSING ALLDRESS 6 X 6,491527,CDM,270,RC,,,Outpatient,,,27.5,16.5,,23.38,85,,18.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.01,80.03,,17.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,90,,19.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.2,88,,19.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.11,33.11,,7.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.84,24.75,
DRESSING ALLDRESS 4 X 6,491529,CDM,270,RC,,,Outpatient,,,27.5,16.5,,23.38,85,,18.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.01,80.03,,17.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,90,,19.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.84,32.15,,7.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.2,88,,19.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.11,33.11,,7.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.84,24.75,
ANTILIRIUM : 2ML AMPS,293013,CDM,250,RC,,,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
FLAGYL (metronidazole) 500MG/NS 100ML PB,293083,CDM,250,RC,S0030,HCPCS,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
NEOMYCIN: 500MG IN,293119,CDM,250,RC,,,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
TUBOCURARINE INJ,293198,CDM,250,RC,,,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
FLAGYL (metronidazole): variable 500mg d,293531,CDM,250,RC,S0030,HCPCS,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
XYLOCAINE 2% VISCOUS (LIDOCAINE) : 100ML,295504,CDM,250,RC,,,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
FURACIN SOL DRESSING 28GM,297022,CDM,250,RC,,,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
VASOCON REG (naphazoline) OPHTH SOL 15ML,297735,CDM,250,RC,,,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
KETO DIASTIX 100'S,292024,CDM,270,RC,,,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.86,32.15,,7.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.13,33.11,,7.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.86,24.8,
DESFERAL : 500MG INJ,293064,CDM,636,RC,J0895,HCPCS,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,8.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.59,24.8,
SOLU CORTEF (hydrocortisone) 500MG INJ,293168,CDM,636,RC,J1720,HCPCS,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,17.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.67,24.8,
XYLOC1% W/EPI (LIDO 1/EPI200K)MPF: 30ML,293214,CDM,636,RC,J2001,HCPCS,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,24.8,
INFED (DEXFERRUM) 100MG /2ML INJ,293245,CDM,636,RC,J1750,HCPCS,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.75,102,,,fee schedule,Pays at 102% of CMS APC rate,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.75,100,,,fee schedule,Pays at 100% of CMS APC rate,17.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.41,24.8,
UNASYN (amp/sulbactam):1.5G VIAL,293384,CDM,636,RC,J0295,HCPCS,Outpatient,,,27.56,16.54,,23.43,85,,18.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.06,80.03,,17.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.8,90,,19.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.25,88,,19.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.05,24.8,
CATHETER FOLEY 24FR 5CC RIBBED BALLOON,49411,CDM,270,RC,,,Outpatient,,,27.75,16.65,,23.59,85,,18.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.92,32.15,,7.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.21,80.03,,17.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.98,90,,19.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.92,32.15,,7.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.92,32.15,,7.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.42,88,,19.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.19,33.11,,7.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.92,24.98,
..GLUCOSE EACH,1882959,CDM,300,RC,82952,HCPCS,Outpatient,,,27.75,16.65,,23.59,85,,18.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.21,80.03,,17.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.98,90,,19.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.42,88,,19.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,24.98,
Q FEVER IGG PHASE I SCREEN  (MAYO),1886724,CDM,300,RC,86658,HCPCS,Outpatient,,,27.75,16.65,,23.59,85,,18.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.21,80.03,,17.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.98,90,,19.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.42,88,,19.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.38,24.98,
Q FEVER IGG PHASE II SCREEN  (MAYO),1886725,CDM,300,RC,86658,HCPCS,Outpatient,,,27.75,16.65,,23.59,85,,18.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.21,80.03,,17.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.98,90,,19.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.42,88,,19.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.38,24.98,
Q FEVER IGM PHASE I SCREEN  (MAYO),1886726,CDM,300,RC,86658,HCPCS,Outpatient,,,27.75,16.65,,23.59,85,,18.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.21,80.03,,17.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.98,90,,19.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.42,88,,19.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.38,24.98,
Q FEVER IGM PHASE II SCREEN  (MAYO),1886727,CDM,300,RC,86658,HCPCS,Outpatient,,,27.75,16.65,,23.59,85,,18.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.21,80.03,,17.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,24.98,90,,19.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.42,88,,19.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.38,24.98,
EXAM/SELECTION OF RETRIEVED ARCHIVAL,2188326,CDM,300,RC,88363,HCPCS,Outpatient,,,27.75,16.65,,23.59,85,,18.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.21,80.03,,17.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,24.98,90,,19.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,22.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.42,88,,19.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.21,24.98,
DIFLUCAN (fluconazole) 150 MG TAB,291019,CDM,250,RC,,,Outpatient,,,27.9,16.74,,23.72,85,,18.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.97,32.15,,7.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.33,80.03,,17.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.11,90,,20.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.97,32.15,,7.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,8.97,32.15,,7.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.55,88,,19.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.24,33.11,,7.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.97,25.11,
SOLU MEDROL (methylprednisolone)125MGINJ,293170,CDM,636,RC,J2930,HCPCS,Outpatient,,,27.9,16.74,,23.72,85,,18.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.33,80.03,,17.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.11,90,,20.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.55,88,,19.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.99,25.11,
MUCOMYST (acetylcysteine) 10% 10ML VIAL,292038,CDM,250,RC,,,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.27,33.11,,7.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9,25.2,
CATAPRES (CLONIDINE) TTS-2 PATCH,292103,CDM,250,RC,,,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.27,33.11,,7.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9,25.2,
ZEMURON (rocuronium) INJ: 5ML,293405,CDM,250,RC,,,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.27,33.11,,7.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9,25.2,
ZAP SOLN 5ML-XYLOC/ADREN/PONTOCAINE,293423,CDM,250,RC,,,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.27,33.11,,7.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9,25.2,
SLIDING SCALE-DR MILLS,293588,CDM,250,RC,J1815,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,25.2,
DRESSING TENDERWET 4  X 5,498031,CDM,272,RC,,,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.27,33.11,,7.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9,25.2,
..URINALYSIS- MICROSCOPIC,1881002,CDM,300,RC,81015,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.11,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.11,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.82,25.2,
PH BLOOD (VENOUS),1882800,CDM,300,RC,82800,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.65,25.2,
Test to measure creatinine in the urine,1883041,CDM,300,RC,82570,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,25.2,
Blood test to screen for syphilis,1886589,CDM,300,RC,86592,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.65,25.2,
PHENOBARBITAL: 65MG INJ,293288,CDM,636,RC,J2560,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,36.97,102,,,fee schedule,Pays at 102% of CMS APC rate,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.97,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.34,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.41,36.25,
DEPO-TESTADIOL MDV  1ML DOSE,293511,CDM,636,RC,J1071,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,25.2,
Outpatient visit of established patient not requiring a physician,11022,CDM,761,RC,99211,HCPCS,Outpatient,,,28,16.8,,23.8,85,,19.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.41,80.03,,17.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.2,90,,20.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9,32.15,,7.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.64,88,,19.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.27,33.11,,7.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9,25.2,
O/T THERABAND,59305,CDM,270,RC,,,Outpatient,,,28.05,16.83,,23.84,85,,19.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.45,80.03,,17.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.25,90,,20.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.68,88,,19.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.25,
O/T THERAPUTTY,59306,CDM,270,RC,,,Outpatient,,,28.05,16.83,,23.84,85,,19.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.45,80.03,,17.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.25,90,,20.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.68,88,,19.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.25,
ZITHROMAX (azithromycin) 250MG TAB,29634,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
HUMAN REG INSULIN FOR SLIDING SCALE,293181,CDM,250,RC,J1815,HCPCS,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,25.26,
NEBCIN (tobramycin) DOSING PER PHARMACY,293191,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
DEXTROSE 25% (PEDI): ABBJ 10ML,293236,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
NITROGLYCERIN: 50MG/10ML INJ,293284,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
REG INSULIN FOR SLIDING SCALE,293502,CDM,250,RC,J1820,HCPCS,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
SLIDING SCALE REGULAR INSULIN,293504,CDM,250,RC,J1820,HCPCS,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
PRIMAXIN -  DOSING PER PHARMACY,293548,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
LOPROX (CICLOPIROX) 0.77% (1%) CRM 15GM,297068,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
CYCLOGYL (CYCLOPENTOLATE) 1% OPTH 2ML,297509,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
INFLAMASE FTE 1%OPTHSOL,297712,CDM,250,RC,,,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
ALDOMET (methyldopa): 250MG/5ML INJ,293005,CDM,636,RC,J0210,HCPCS,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.02,32.15,,7.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.29,33.11,,7.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.02,25.26,
NEBCIN (tobramycin) : 80MG VIAL,293366,CDM,636,RC,J3260,HCPCS,Outpatient,,,28.07,16.84,,23.86,85,,19.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.46,80.03,,17.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.26,90,,20.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.7,88,,19.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.65,25.26,
Urine test to measure albumin,1884231,CDM,300,RC,82043,HCPCS,Outpatient,,,28.09,16.85,,23.88,85,,19.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.48,80.03,,17.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.28,90,,20.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.72,88,,19.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.28,25.28,
Blood test indicating infection with Hepatitis B,1886289,CDM,300,RC,86704,HCPCS,Outpatient,,,28.12,16.87,,23.9,85,,19.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.5,80.03,,18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.31,90,,20.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.75,88,,19.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,25.31,
DRESSING XEROFORM 5 X 9,491401,CDM,270,RC,,,Outpatient,,,28.13,16.88,,23.91,85,,19.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.04,32.15,,7.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.51,80.03,,18.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.32,90,,20.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.04,32.15,,7.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.04,32.15,,7.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.75,88,,19.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.31,33.11,,7.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.04,25.32,
BANDAGE ELST MATRIX STRL 6 X15YD,493055,CDM,270,RC,,,Outpatient,,,28.13,16.88,,23.91,85,,19.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.04,32.15,,7.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.51,80.03,,18.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.32,90,,20.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.04,32.15,,7.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.04,32.15,,7.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.75,88,,19.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.31,33.11,,7.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.04,25.32,
LIPO PROTEIN A  (MAYO),1883714,CDM,300,RC,83695,HCPCS,Outpatient,,,28.25,16.95,,24.01,85,,19.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.61,80.03,,18.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.43,90,,20.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.86,88,,19.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,25.43,
LAMISIL (terbinafine) 250 MG TAB,291013,CDM,250,RC,,,Outpatient,,,28.35,17.01,,24.1,85,,19.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.11,32.15,,7.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.69,80.03,,18.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.52,90,,20.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.11,32.15,,7.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.11,32.15,,7.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.95,88,,19.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.39,33.11,,7.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.11,25.52,
SODIUM BICARB: 50MEQ/50ML ABBJ,293161,CDM,250,RC,,,Outpatient,,,28.35,17.01,,24.1,85,,19.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.11,32.15,,7.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.69,80.03,,18.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.52,90,,20.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.11,32.15,,7.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.11,32.15,,7.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.95,88,,19.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.39,33.11,,7.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.11,25.52,
TEQUIN 400MG TAB *DISCONTINUED*,29557,CDM,250,RC,,,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
TEQUIN 200 MG TAB *DISCONTINUED*,29563,CDM,250,RC,,,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
SODIUM BICARB : 50MEQ/50ML VIAL,293160,CDM,250,RC,,,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
"DRESSING, VAC TRAC PAD",438839,CDM,270,RC,,,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
NEEDLE SPCLTY HYPO 30GX1  RG BVL STR,491653,CDM,270,RC,,,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
NEEDLE HYPODERMIC 25GX1.5  RG BVL STR,491654,CDM,270,RC,,,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
KIT TELEMETRY ICU,498500,CDM,270,RC,,,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
PH (BODY FLUID) (MAYO),1883986,CDM,300,RC,83986,HCPCS,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.5,25.65,
"FLOW CYTO, EACH ADDL MARKER, TC",2188185,CDM,311,RC,88185,HCPCS,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.5,,,,Other,Not Separately reimbursable,22.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.67,25.65,
PAPAVERINE 30MG/ML INJ,298065,CDM,636,RC,J2440,HCPCS,Outpatient,,,28.5,17.1,,24.23,85,,19.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.81,80.03,,18.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,20.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.5,,,,Other,Not Separately reimbursable,9.16,32.15,,7.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.08,88,,20.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.44,33.11,,7.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.16,25.65,
BETADINE VAGINAL GEL 30Z,292022,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
DOPAMINE: 400MG INJ,293274,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
LOTRIMIN CRM (CLOTRIMAZOLE) 1% 15GM,297028,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
KENALOG/ORABASE (TRIAMCINOLONE) 5GM,297033,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
MONISTAT DERM (MICONAZOLE) CREAM,297071,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
MAXITROL (DEXA/NEO/POLYMIX) OPTH OINT,297519,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
PRED MILD (PREDNISOLONE)0.12% OPTH:5ML,297729,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
AURALGAN OTIC SOLN 10ML,297801,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
VOSOL OTIC SOL,297810,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
POLYTRIM OPTH SOLN 10ML,2957809,CDM,250,RC,,,Outpatient,,,28.59,17.15,,24.3,85,,19.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.88,80.03,,18.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.73,90,,20.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.59,,,,Other,Not Separately reimbursable,9.19,32.15,,7.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.16,88,,20.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,33.11,,7.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.19,25.73,
THIAMINE 100MG/ML 2ML INJ,293188,CDM,250,RC,J3411,HCPCS,Outpatient,,,28.67,17.2,,24.37,85,,19.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.22,32.15,,7.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.94,80.03,,18.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.8,90,,20.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.22,32.15,,7.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.67,,,,Other,Not Separately reimbursable,9.22,32.15,,7.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.23,88,,20.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.49,33.11,,7.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.22,25.8,
DRESSING FOAM 4 X4  HYDRO BLUE,498052,CDM,270,RC,,,Outpatient,,,28.75,17.25,,24.44,85,,19.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.24,32.15,,7.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.01,80.03,,18.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.88,90,,20.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.24,32.15,,7.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.75,,,,Other,Not Separately reimbursable,9.24,32.15,,7.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.3,88,,20.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.52,33.11,,7.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.24,25.88,
Quantitative measure of glucose build up in the blood over time,1882947,CDM,300,RC,82947,HCPCS,Outpatient,,,28.91,17.35,,24.57,85,,19.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.14,80.03,,18.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.02,90,,20.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.44,88,,20.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,26.02,
".FLU - A, RAPID TEST",1886712,CDM,300,RC,87400,HCPCS,Outpatient,,,28.91,17.35,,24.57,85,,19.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.14,80.03,,18.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.41,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.02,90,,20.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.41,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.44,88,,20.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,26.02,
".FLU - B, RAPID TEST",1886713,CDM,300,RC,87400,HCPCS,Outpatient,,,28.91,17.35,,24.57,85,,19.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.14,80.03,,18.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.41,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.02,90,,20.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.41,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.44,88,,20.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,26.02,
CHIROCAINE (LEVOBUPIV) 5MG/ML: 30ML VIAL,292113,CDM,250,RC,,,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.6,33.11,,7.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.32,26.1,
CHIROCAINE (LEVOBUPIVI) 2.5MG/ML : 30ML,292116,CDM,250,RC,,,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.6,33.11,,7.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.32,26.1,
DIPRIVAN (propofol) 10MG/ML 100 ML,293830,CDM,250,RC,,,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.6,33.11,,7.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.32,26.1,
CORTISPORIN OTIC SOL 10ML,297804,CDM,250,RC,,,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.6,33.11,,7.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.32,26.1,
TRAY SKIN STAPLE REMOVER,495140,CDM,270,RC,,,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.6,33.11,,7.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.32,26.1,
SORBACT CUTIMED WCL 4  X 8,498007,CDM,270,RC,,,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.6,33.11,,7.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.32,26.1,
"PHOSPHOROUS, 24HR URINE  (MAYO)",1882197,CDM,300,RC,84105,HCPCS,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,26.1,
SPONGE 4X4 X-RAY DETECTABLE STERILE,493064,CDM,270,RC,,,Outpatient,,,29.06,17.44,,24.7,85,,19.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.34,32.15,,7.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.26,80.03,,18.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.15,90,,20.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.34,32.15,,7.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.34,32.15,,7.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.57,88,,20.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.62,33.11,,7.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.34,26.15,
SUTURE POLYSORB 5.0 18  UNDYED,4900639,CDM,270,RC,,,Outpatient,,,29.06,17.44,,24.7,85,,19.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.34,32.15,,7.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.26,80.03,,18.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.15,90,,20.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.34,32.15,,7.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.34,32.15,,7.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.57,88,,20.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.62,33.11,,7.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.34,26.15,
GENTAMICIN 0.3% OPHTH SOLN 5ML,297711,CDM,250,RC,,,Outpatient,,,29.1,17.46,,24.74,85,,19.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.36,32.15,,7.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.29,80.03,,18.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.19,90,,20.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.36,32.15,,7.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.36,32.15,,7.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.61,88,,20.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.64,33.11,,7.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.36,26.19,
Blood test to determine autoimmune disorders,1886039,CDM,300,RC,86039,HCPCS,Outpatient,,,29.2,17.52,,24.82,85,,19.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.37,80.03,,18.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.28,90,,21.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.7,88,,20.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.04,26.28,
CARDIAC APNEA MONITOR HOURLY,8010,CDM,270,RC,,,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
NURS CARDIAC APNEA HRLY,28025,CDM,270,RC,,,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
POUCH DISPOSABLE CARRYING,49379,CDM,270,RC,,,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
STOPCOCK THREE-WAY DISPOSABLE,493288,CDM,270,RC,,,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
TUBE ENDO HOLDER,493775,CDM,270,RC,,,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
Manual urinalysis test with examination without using microscope,681002,CDM,300,RC,81002,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.54,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.54,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.21,26.33,
GASTRIN LEVEL  (MAYO),1882941,CDM,300,RC,82941,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.98,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.98,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.18,26.33,
"SPECIFIC GRAVITY, BODY FLUID",1884000,CDM,300,RC,84315,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.15,26.33,
Outpatient visit of established patient requiring a physician,11019,CDM,761,RC,99212,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
OP OBSERVATION SURG,4003,CDM,762,RC,99218,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
OP OBSERVATION,4011,CDM,762,RC,G0244,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
OP OBSERVATION,4012,CDM,762,RC,G0264,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
OP OBSERVATION,4014,CDM,762,RC,G0263,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
OP OBSERVATION PED,5003,CDM,762,RC,99218,HCPCS,Outpatient,,,29.25,17.55,,24.86,85,,19.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.41,80.03,,18.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.33,90,,21.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.4,32.15,,7.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.74,88,,20.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.68,33.11,,7.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.4,26.33,
ZYPREXA (olanzapine) 5MG TAB,29656,CDM,250,RC,,,Outpatient,,,29.33,17.6,,24.93,85,,19.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.43,32.15,,7.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.47,80.03,,18.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.4,90,,21.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.43,32.15,,7.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.43,32.15,,7.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.81,88,,20.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.71,33.11,,7.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.43,26.4,
LASIX (furosemide) 10MG/ML SOLN: 60ML,296040,CDM,250,RC,,,Outpatient,,,29.36,17.62,,24.96,85,,19.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.5,80.03,,18.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.42,90,,21.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.84,88,,20.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.72,33.11,,7.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.44,26.42,
SOD SULAMYD OPTH OINT,297513,CDM,250,RC,,,Outpatient,,,29.36,17.62,,24.96,85,,19.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.5,80.03,,18.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.42,90,,21.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.84,88,,20.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.72,33.11,,7.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.44,26.42,
SOD SULAMYD 10% O/S 15ML,297730,CDM,250,RC,,,Outpatient,,,29.36,17.62,,24.96,85,,19.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.5,80.03,,18.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.42,90,,21.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.44,32.15,,7.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.84,88,,20.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.72,33.11,,7.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.44,26.42,
DRAPE VAC ADHESIVE 30.5 X 26CM,49682,CDM,270,RC,,,Outpatient,,,29.5,17.7,,25.08,85,,20.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.48,32.15,,7.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.61,80.03,,18.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.55,90,,21.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.48,32.15,,7.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.48,32.15,,7.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.96,88,,20.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.77,33.11,,7.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.48,26.55,
FREE VALPROIC ACID  (MAYO),1882664,CDM,300,RC,80164,HCPCS,Outpatient,,,29.5,17.7,,25.08,85,,20.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.61,80.03,,18.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.55,90,,21.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.96,88,,20.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.27,26.55,
CRYPTOCOCCUS AG,1886005,CDM,300,RC,86641,HCPCS,Outpatient,,,29.53,17.72,,25.1,85,,20.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.63,80.03,,18.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.58,90,,21.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.99,88,,20.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.13,26.58,
"OSMOLALITY, URINE  (MAYO)",1883935,CDM,300,RC,83935,HCPCS,Outpatient,,,29.69,17.81,,25.24,85,,20.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.76,80.03,,19.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,26.72,90,,21.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.13,88,,20.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.57,26.72,
DRESSING MULTI-TRAUMA 12 X 30,493057,CDM,270,RC,,,Outpatient,,,29.75,17.85,,25.29,85,,20.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.56,32.15,,7.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.81,80.03,,19.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,90,,21.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.56,32.15,,7.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.56,32.15,,7.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.18,88,,20.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.85,33.11,,7.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.56,26.78,
ERYTHROMYCIN OPHTH OINT. UD,297521,CDM,250,RC,,,Outpatient,,,29.79,17.87,,25.32,85,,20.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.58,32.15,,7.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.84,80.03,,19.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.81,90,,21.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.58,32.15,,7.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.58,32.15,,7.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.22,88,,20.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.86,33.11,,7.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.58,26.81,
TRANSDERM-SCOP (scopolamine) PATCH,292068,CDM,250,RC,,,Outpatient,,,29.85,17.91,,25.37,85,,20.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.89,80.03,,19.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.87,90,,21.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.27,88,,21.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.88,33.11,,7.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.6,26.87,
CARDIZEM (diltiazem): 25MG INJ,213130,CDM,250,RC,,,Outpatient,,,29.87,17.92,,25.39,85,,20.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.9,80.03,,19.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.88,90,,21.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.29,88,,21.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.89,33.11,,7.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.6,26.88,
DELATESTRYL 200MG/1ML INJ,293058,CDM,250,RC,,,Outpatient,,,29.87,17.92,,25.39,85,,20.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.9,80.03,,19.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.88,90,,21.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.29,88,,21.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.89,33.11,,7.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.6,26.88,
NITROSTAT 8MG/10ML INJ,293126,CDM,250,RC,,,Outpatient,,,29.87,17.92,,25.39,85,,20.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.9,80.03,,19.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.88,90,,21.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.29,88,,21.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.89,33.11,,7.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.6,26.88,
GYNE-LOTRIMIN VAG CREAM,296085,CDM,250,RC,,,Outpatient,,,29.87,17.92,,25.39,85,,20.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.9,80.03,,19.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.88,90,,21.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.29,88,,21.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.89,33.11,,7.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.6,26.88,
GENTAMICIN OPHTH OINT 3.5 GRAMS,297505,CDM,250,RC,,,Outpatient,,,29.87,17.92,,25.39,85,,20.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.9,80.03,,19.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.88,90,,21.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.6,32.15,,7.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.29,88,,21.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.89,33.11,,7.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.6,26.88,
PT E- VISIT 5-10 MIN,312061,CDM,420,RC,G2061,HCPCS,Outpatient,,,29.88,17.93,,25.4,85,,20.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.61,32.15,,7.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.91,80.03,,19.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.89,90,,21.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.61,32.15,,7.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.61,32.15,,7.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.29,88,,21.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.89,33.11,,7.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.61,26.89,
"OT E-VISIT, 5-10 MIN",592061,CDM,420,RC,G2061,HCPCS,Outpatient,,,29.88,17.93,,25.4,85,,20.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.61,32.15,,7.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.91,80.03,,19.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.89,90,,21.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.61,32.15,,7.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.61,32.15,,7.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.29,88,,21.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.89,33.11,,7.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.61,26.89,
ZOSYN 2.25GM VIAL - RX COMPOUND,300648,CDM,250,RC,,,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
PARR O2,30180,CDM,270,RC,,,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
EQUIPMENT CHANGE OUT,30295,CDM,270,RC,,,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
KIT ORAL SUCTION READY CARE,30336,CDM,270,RC,,,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
.METERED DOSE INHALER ADAPTER,30390,CDM,270,RC,,,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
A technique used by physical therapists to restore normal body movement patterns,31114,CDM,270,RC,97112,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
INTERNAL DEFIB,493761,CDM,270,RC,,,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
DAILY - CREATININE,1880010,CDM,300,RC,82565,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,27,
"BILIRUBIN, TOTAL",1882250,CDM,300,RC,82247,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,27,
"CALCIUM, SERUM",1882310,CDM,300,RC,82310,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.26,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.26,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,27,
CHOLESTEROL,1882465,CDM,300,RC,82465,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.43,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.43,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.47,27,
Test to determine levels of immunoglobulins in the blood,1882782,CDM,300,RC,82784,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.69,27,
Test to determine levels of immunoglobulins in the blood,1882783,CDM,300,RC,82784,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.69,27,
ALKALINE PHOSPHATASE,1884075,CDM,300,RC,84075,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,27,
"PROTEIN,TOTAL, SERUM",1884155,CDM,300,RC,84155,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.61,27,
"URINE PROTEIN, RANDOM",1884157,CDM,300,RC,84156,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.61,27,
CSF PROTEIN,1884195,CDM,300,RC,84157,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.61,27,
TRIGLYCERIDES,1884478,CDM,300,RC,84478,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,27,
BUN,1884520,CDM,300,RC,84520,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.96,27,
Test to determine levels of immunoglobulins in the blood,1886329,CDM,300,RC,82784,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.69,27,
AFB SMEAR (MYCOBACT),1887116,CDM,300,RC,87206,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,27,
Repeated application to one or more parts of the body,31104,CDM,420,RC,97032,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
DO NOT USE,311008,CDM,420,RC,97018,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.47,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.47,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
Use of massage,311010,CDM,420,RC,97124,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",311014,CDM,420,RC,97035,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
A type of physical therapy,311016,CDM,420,RC,97116,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311024,CDM,420,RC,97110,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
P/T CONSULT/EDUCATE I-15 MIN,311032,CDM,420,RC,97139,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
Manipulation of 1 or more regions of the body,3110015,CDM,420,RC,97140,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
DO NOT USE,3112051,CDM,420,RC,97139,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
O/T RANGE OF MOTION/MOBILITY,59003,CDM,430,RC,95833,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
Manipulation of 1 or more regions of the body,590010,CDM,430,RC,97140,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
DIPHTHERIA & TETANUS(DT)CHILD 7 OR UNDER,1490702,CDM,450,RC,90702,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
MERREM ( meropenem)  500MG VIAL,292143,CDM,636,RC,J2185,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.56,27,
GENTAMICIN 80MG/100ML NS IVPB,300168,CDM,636,RC,J1580,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,27,
DO NOT USE,3110011,CDM,922,RC,95831,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
DO NOT USE,3110012,CDM,922,RC,95833,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
P/T RANGE OF MOTION/MOBILITY TEST,3110013,CDM,922,RC,95851,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.7,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7.7,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
Use of EKG to monitor cardiac rehabilitation,311022,CDM,943,RC,93798,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,115.11,102,,,fee schedule,Pays at 102% of CMS APC rate,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.11,100,,,fee schedule,Pays at 100% of CMS APC rate,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
D5W 50ML,296150,CDM,258,RC,J7060,HCPCS,Outpatient,,,30.2,18.12,,25.67,85,,20.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.17,80.03,,19.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.18,90,,21.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.58,88,,21.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.63,27.18,
LDH,1883620,CDM,300,RC,83615,HCPCS,Outpatient,,,30.2,18.12,,25.67,85,,20.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.17,80.03,,19.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27.18,90,,21.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.58,88,,21.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,27.18,
"INSULIN, TOTAL SERUM  (MAYO)",1882214,CDM,300,RC,83525,HCPCS,Outpatient,,,30.25,18.15,,25.71,85,,20.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.21,80.03,,19.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27.23,90,,21.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.62,88,,21.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.38,27.23,
STRAINERS URINE,493292,CDM,270,RC,,,Outpatient,,,30.31,18.19,,25.76,85,,20.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.74,32.15,,7.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.26,80.03,,19.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.28,90,,21.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.74,32.15,,7.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.74,32.15,,7.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.67,88,,21.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.04,33.11,,8.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.74,27.28,
VALVE LUER ACCESS CARESITE,492147,CDM,270,RC,,,Outpatient,,,30.34,18.2,,25.79,85,,20.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.75,32.15,,7.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.28,80.03,,19.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.31,90,,21.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.75,32.15,,7.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.75,32.15,,7.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.7,88,,21.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.05,33.11,,8.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.75,27.31,
AMOXICILLIN 200MG/5ML: 100ML,294006,CDM,250,RC,,,Outpatient,,,30.35,18.21,,25.8,85,,20.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.76,32.15,,7.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.29,80.03,,19.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.32,90,,21.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.76,32.15,,7.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.76,32.15,,7.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.71,88,,21.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.05,33.11,,8.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.76,27.32,
METAPREL INHALER 15ML,292045,CDM,250,RC,,,Outpatient,,,30.39,18.23,,25.83,85,,20.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.32,80.03,,19.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.35,90,,21.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.74,88,,21.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.06,33.11,,8.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.77,27.35,
CALAN (verapamil) 5MG/2ML INJ,293029,CDM,250,RC,,,Outpatient,,,30.39,18.23,,25.83,85,,20.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.32,80.03,,19.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.35,90,,21.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.74,88,,21.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.06,33.11,,8.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.77,27.35,
PRODERM TOP DRESS 4OZ,298052,CDM,250,RC,,,Outpatient,,,30.39,18.23,,25.83,85,,20.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.32,80.03,,19.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.35,90,,21.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.77,32.15,,7.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.74,88,,21.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.06,33.11,,8.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.77,27.35,
SOLU MEDROL (methylprednisolone)500MG IN,293171,CDM,636,RC,J2930,HCPCS,Outpatient,,,30.39,18.23,,25.83,85,,20.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.32,80.03,,19.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.35,90,,21.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.74,88,,21.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.99,27.35,
DEPO-MEDROL INJECTION SUSP 40MG/1ML,293104,CDM,636,RC,J1030,HCPCS,Outpatient,,,30.43,18.26,,25.87,85,,20.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.35,80.03,,19.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.39,90,,21.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,7.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.78,88,,21.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.2,27.39,
CATHETER FOLEY 18FR 5CC LF 2-WAY,49401,CDM,270,RC,,,Outpatient,,,30.5,18.3,,25.93,85,,20.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.41,80.03,,19.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.45,90,,21.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.84,88,,21.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.1,33.11,,8.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.81,27.45,
CATHETER FOLEY 22FR 5CC LF 2-WAY,49403,CDM,270,RC,,,Outpatient,,,30.5,18.3,,25.93,85,,20.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.41,80.03,,19.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.45,90,,21.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.84,88,,21.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.1,33.11,,8.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.81,27.45,
TRANSEPTIC SOLUTION,225053,CDM,270,RC,,,Outpatient,,,30.5,18.3,,25.93,85,,20.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.41,80.03,,19.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.45,90,,21.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.84,88,,21.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.1,33.11,,8.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.81,27.45,
COLLECTION SET D/C BERKELEY,491808,CDM,270,RC,,,Outpatient,,,30.5,18.3,,25.93,85,,20.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.41,80.03,,19.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.45,90,,21.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.84,88,,21.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.1,33.11,,8.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.81,27.45,
COVER FLURO STERILE,493682,CDM,270,RC,,,Outpatient,,,30.5,18.3,,25.93,85,,20.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.41,80.03,,19.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.45,90,,21.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.84,88,,21.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.1,33.11,,8.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.81,27.45,
OP OBSERVATION OB,6003,CDM,762,RC,99218,HCPCS,Outpatient,,,30.5,18.3,,25.93,85,,20.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.41,80.03,,19.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.45,90,,21.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.81,32.15,,7.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.84,88,,21.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.1,33.11,,8.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.81,27.45,
DIP/PIP STRAP,426,CDM,270,RC,,,Outpatient,,,30.55,18.33,,25.97,85,,20.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.82,32.15,,7.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.45,80.03,,19.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.5,90,,22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.82,32.15,,7.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.82,32.15,,7.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.88,88,,21.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.12,33.11,,8.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.82,27.5,
CUSHION INVALID,49858,CDM,270,RC,,,Outpatient,,,30.75,18.45,,26.14,85,,20.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.89,32.15,,7.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.61,80.03,,19.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.68,90,,22.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.89,32.15,,7.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.89,32.15,,7.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.06,88,,21.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.18,33.11,,8.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.89,27.68,
IV START KIT,496531,CDM,270,RC,,,Outpatient,,,30.75,18.45,,26.14,85,,20.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.89,32.15,,7.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.61,80.03,,19.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.68,90,,22.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.89,32.15,,7.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.89,32.15,,7.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.06,88,,21.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.18,33.11,,8.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.89,27.68,
"PHOSPHOROUS, FECES, QT  (MAYO)",1884309,CDM,300,RC,84100,HCPCS,Outpatient,,,30.75,18.45,,26.14,85,,20.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.61,80.03,,19.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27.68,90,,22.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.06,88,,21.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.97,27.68,
STER WATER IRG 3000ML,302612,CDM,258,RC,,,Outpatient,,,30.84,18.5,,26.21,85,,20.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.92,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.68,80.03,,19.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.76,90,,22.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.92,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.92,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.14,88,,21.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.21,33.11,,8.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.92,27.76,
DYNAPEN (DICLOXACILL) 62.5MG/5ML SUSP80,294049,CDM,250,RC,,,Outpatient,,,30.9,18.54,,26.27,85,,21.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.73,80.03,,19.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.81,90,,22.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.19,88,,21.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.23,33.11,,8.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.93,27.81,
ISOPTO CARPINE 3% O/S,297717,CDM,250,RC,,,Outpatient,,,30.9,18.54,,26.27,85,,21.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.73,80.03,,19.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.81,90,,22.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.19,88,,21.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.23,33.11,,8.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.93,27.81,
VASOCON-A/VISINE-A OPHTH SOL 15ML,297736,CDM,250,RC,,,Outpatient,,,30.9,18.54,,26.27,85,,21.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.73,80.03,,19.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.81,90,,22.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.93,32.15,,7.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.19,88,,21.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.23,33.11,,8.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.93,27.81,
LR  (lactated ringers) :250ML,296247,CDM,258,RC,J7120,HCPCS,Outpatient,,,30.9,18.54,,26.27,85,,21.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.73,80.03,,19.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.81,90,,22.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.19,88,,21.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.45,27.81,
LR (lactated ringers) :500ml,296248,CDM,258,RC,J7120,HCPCS,Outpatient,,,30.9,18.54,,26.27,85,,21.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.73,80.03,,19.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.81,90,,22.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.19,88,,21.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.45,27.81,
METHOTREXATE INJ: 50MG /2ML,29344,CDM,636,RC,J9250,HCPCS,Outpatient,,,30.9,18.54,,26.27,85,,21.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.73,80.03,,19.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.81,90,,22.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.19,88,,21.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.23,27.81,
pneumococcal Pneumococcal vaccine,293277,CDM,636,RC,90732,HCPCS,Outpatient,,,30.9,18.54,,26.27,85,,21.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.73,80.03,,19.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.81,90,,22.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,133.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.19,88,,21.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.73,133.47,
CATH SUCTION 6FR DELEE TIP,49734,CDM,270,RC,,,Outpatient,,,31,18.6,,26.35,85,,21.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.97,32.15,,7.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.81,80.03,,19.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.9,90,,22.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.97,32.15,,7.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.97,32.15,,7.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.28,88,,21.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.26,33.11,,8.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.97,27.9,
DIAPERS SZ4 WALKER 22LBS & OVER,49877,CDM,270,RC,,,Outpatient,,,31,18.6,,26.35,85,,21.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.97,32.15,,7.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.81,80.03,,19.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.9,90,,22.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.97,32.15,,7.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,9.97,32.15,,7.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.28,88,,21.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.26,33.11,,8.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.97,27.9,
ALDOLASE  (MAYO),1882086,CDM,300,RC,82085,HCPCS,Outpatient,,,31,18.6,,26.35,85,,21.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.81,80.03,,19.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27.9,90,,22.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.28,88,,21.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.2,27.9,
Test of a wound for type of bacterial infection,1887074,CDM,300,RC,87077,HCPCS,Outpatient,,,31,18.6,,26.35,85,,21.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.81,80.03,,19.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,27.9,90,,22.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.28,88,,21.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.16,27.9,
DEXTROSE 50%: ABBOJECT 50ML,293066,CDM,250,RC,,,Outpatient,,,31.25,18.75,,26.56,85,,21.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.01,80.03,,20.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.13,90,,22.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.5,88,,22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.35,33.11,,8.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.05,28.13,
ARTHROGRAM TRAY,22405,CDM,270,RC,,,Outpatient,,,31.25,18.75,,26.56,85,,21.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.01,80.03,,20.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.13,90,,22.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.5,88,,22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.35,33.11,,8.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.05,28.13,
CATH IV INTROCAN 18G X 1 1/4,496307,CDM,270,RC,,,Outpatient,,,31.25,18.75,,26.56,85,,21.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.01,80.03,,20.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.13,90,,22.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.05,32.15,,8.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.5,88,,22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.35,33.11,,8.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.05,28.13,
"AMYLASE, URINE",1882156,CDM,300,RC,82150,HCPCS,Outpatient,,,31.25,18.75,,26.56,85,,21.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.01,80.03,,20.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.13,90,,22.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.5,88,,22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.15,28.13,
Quantitative measure of glucose build up in the blood over time,3001,CDM,300,RC,82947,HCPCS,Outpatient,,,31.37,18.82,,26.66,85,,21.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.11,80.03,,20.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.23,90,,22.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.61,88,,22.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,28.23,
Quantitative measure of glucose build up in the blood over time,8001,CDM,300,RC,82947,HCPCS,Outpatient,,,31.37,18.82,,26.66,85,,21.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.11,80.03,,20.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.23,90,,22.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.61,88,,22.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,28.23,
UNIPEN (nafcillin) : 1GM VIAL,293385,CDM,250,RC,,,Outpatient,,,31.42,18.85,,26.71,85,,21.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.15,80.03,,20.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.28,90,,22.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.65,88,,22.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.4,33.11,,8.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.1,28.28,
TEGOPEN 125MG/5ML SY : 100ML,294030,CDM,250,RC,,,Outpatient,,,31.42,18.85,,26.71,85,,21.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.15,80.03,,20.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.28,90,,22.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.65,88,,22.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.4,33.11,,8.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.1,28.28,
NIZORAL (KETOCONAZOLE) CREAM 15GM,297039,CDM,250,RC,,,Outpatient,,,31.42,18.85,,26.71,85,,21.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.15,80.03,,20.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.28,90,,22.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.1,32.15,,8.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.65,88,,22.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.4,33.11,,8.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.1,28.28,
SANDOSTATIN (OCTREOTIDE) 100MCG/ML INJ,296088,CDM,636,RC,J2354,HCPCS,Outpatient,,,31.42,18.85,,26.71,85,,21.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.15,80.03,,20.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.28,90,,22.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.65,88,,22.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.12,28.28,
LONG HANDLED SPONGE,402,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
PIVOTING SCRUB SPONGE,403,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
DRESSING STICK 18,407,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
DRESSING STICK 27,408,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
ENGLISH SOCK AID,409,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
BUTTON HOOK,413,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
FINGER BUDDY STRAP,418,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
LONG HANDLED SHOEHORN,428,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
MESALT ROPE,436,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
ALLDRESS 4 x 4,438,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
ALLDRESS 6 x 6,439,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
GOMCO SUCTION DAILY,49031,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
PB CRADLE W/O HEAT,49060,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SITZ BATH CHAIR,49070,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
COVER PIN YELLOW,49506,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
COVER PIN BLUE,49507,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
COVER PIN RED,49508,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
CATH ULTRAMER 18FR URETHRAL RED RUBBER,49630,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
CATH ULTRAMER 22FR URETHRAL RED RUBBER,49642,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
TRANSEPTIC SOLUTION,225052,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
POLYFOAM,314007,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SPLINT FINGER FROG SMALL,491309,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SPLINT FINGER FROG  MEDIUM,491310,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SPLINT FINGER FROG  LARGE,491311,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SPLINT BASEBALL FINGER SMALL,491312,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SPLINT BASEBALL FINGER LARGE,491314,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SPONGE OPTIPORE,491512,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
TUBE ENDOTRACHAEL HOLDER/BITE STICK,491741,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SPONGE TONSIL SMALL SINGLE STERILE,493080,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
STRIPS STOMAHESIVE,493233,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
DRESSING DUODERM CGF BORDER 2.5 X 2.5,493267,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
DRESSING DUODERM CGF BORDER 4 X 4,493279,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
CLAMP HEMOSTAT DIALYSSIS DISPOSABLE,493470,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
CATHETER FOLEY 3 WAY 20 FR 30 CC LATEX,495520,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
TUBE GAUZE- BODY/FOOT,496591,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
COLOSTOMY BELT,496905,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
POUCH DRAINABLE CLAMP,497038,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
PACK MAYO STAND DRAPE,499601,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
SET TRANSFER W/SEALING CAP,4980078,CDM,270,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
ER SPECIMEN COLLECTION,14015,CDM,300,RC,,,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
"OSMOLALITY, STOOL  (MAYO)",1883936,CDM,300,RC,84999,HCPCS,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
"SODIUM, FECES, QT  (MAYO)",1884302,CDM,300,RC,84302,HCPCS,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.35,28.35,
"POTASSIUM, FECES, QT  (MAYO)",1884303,CDM,300,RC,84999,HCPCS,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
"CHLORIDE, FECES, QT  (MAYO)",1884304,CDM,300,RC,82438,HCPCS,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.15,28.35,
CAD FOR MRI,27082,CDM,610,RC,0159T,HCPCS,Outpatient,,,31.5,18.9,,26.78,85,,21.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.21,80.03,,20.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.35,90,,22.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,,,,Other,Not Separately reimbursable,10.13,32.15,,8.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.72,88,,22.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.43,33.11,,8.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.13,28.35,
C-TELEPEPTIDE (MAYO),1884681,CDM,300,RC,84681,HCPCS,Outpatient,,,31.75,19.05,,26.99,85,,21.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.41,80.03,,20.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.58,90,,22.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.94,88,,22.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.98,28.58,
..C3 & C4 COMPLEMENT  (MAYO),1886361,CDM,300,RC,86160,HCPCS,Outpatient,,,31.75,19.05,,26.99,85,,21.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.41,80.03,,20.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.58,90,,22.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.94,88,,22.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,28.58,
OXYGEN THERAPY / HR,3017,CDM,270,RC,,,Outpatient,,,31.78,19.07,,27.01,85,,21.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.22,32.15,,8.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.43,80.03,,20.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.6,90,,22.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.22,32.15,,8.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.78,,,,Other,Not Separately reimbursable,10.22,32.15,,8.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.97,88,,22.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.52,33.11,,8.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.22,28.6,
MYCELEX-7 (CLOTRIMAZOLE) VAG CREAM,292015,CDM,250,RC,,,Outpatient,,,31.93,19.16,,27.14,85,,21.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.55,80.03,,20.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.74,90,,22.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.93,,,,Other,Not Separately reimbursable,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.1,88,,22.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.57,33.11,,8.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.27,28.74,
ZANTAC (ranitidine) 50MG /50MLPB*(PYXIS),293545,CDM,250,RC,,,Outpatient,,,31.93,19.16,,27.14,85,,21.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.55,80.03,,20.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.74,90,,22.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.93,,,,Other,Not Separately reimbursable,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.1,88,,22.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.57,33.11,,8.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.27,28.74,
NEOSPORIN (BACI/NEO/POLYMIX) OPTH OINT3.,297508,CDM,250,RC,,,Outpatient,,,31.93,19.16,,27.14,85,,21.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.55,80.03,,20.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.74,90,,22.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.93,,,,Other,Not Separately reimbursable,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.1,88,,22.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.57,33.11,,8.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.27,28.74,
TIMOPTIC (timolol) 0.25% OPTH 5ML,297732,CDM,250,RC,,,Outpatient,,,31.93,19.16,,27.14,85,,21.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.55,80.03,,20.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.74,90,,22.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.93,,,,Other,Not Separately reimbursable,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.1,88,,22.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.57,33.11,,8.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.27,28.74,
ISOPTO CARPINE 4% 15 ML,297746,CDM,250,RC,,,Outpatient,,,31.93,19.16,,27.14,85,,21.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.55,80.03,,20.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.74,90,,22.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.93,,,,Other,Not Separately reimbursable,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.1,88,,22.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.57,33.11,,8.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.27,28.74,
PENTOTHAL (thiopental ) 250MG DOSE,299055,CDM,250,RC,,,Outpatient,,,31.93,19.16,,27.14,85,,21.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.55,80.03,,20.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.74,90,,22.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.93,,,,Other,Not Separately reimbursable,10.27,32.15,,8.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.1,88,,22.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.57,33.11,,8.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.27,28.74,
DRESSING ADAPTIC 3  X 2,49997,CDM,270,RC,,,Outpatient,,,32,19.2,,27.2,85,,21.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.29,32.15,,8.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.61,80.03,,20.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.8,90,,23.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.29,32.15,,8.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32,,,,Other,Not Separately reimbursable,10.29,32.15,,8.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.16,88,,22.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.6,33.11,,8.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.29,28.8,
TISSUE PROCESSING  (MAYO),1885999,CDM,300,RC,87176,HCPCS,Outpatient,,,32,19.2,,27.2,85,,21.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.61,80.03,,20.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.8,90,,23.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.16,88,,22.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.62,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.4,28.8,
"..SALMONELLA ABS, SERUM  (MAYO)",1889055,CDM,300,RC,86768,HCPCS,Outpatient,,,32,19.2,,27.2,85,,21.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.61,80.03,,20.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,28.8,90,,23.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.16,88,,22.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.59,28.8,
CANNULA VACURETTE FLEX TIP 4MM,491815,CDM,270,RC,,,Outpatient,,,32.25,19.35,,27.41,85,,21.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.37,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.81,80.03,,20.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.03,90,,23.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.37,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.25,,,,Other,Not Separately reimbursable,10.37,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.38,88,,22.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.68,33.11,,8.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.37,29.03,
GLYCINE 1.5% IRG 3000ML,296582,CDM,258,RC,,,Outpatient,,,32.28,19.37,,27.44,85,,21.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.38,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.83,80.03,,20.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.05,90,,23.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.38,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.28,,,,Other,Not Separately reimbursable,10.38,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.41,88,,22.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.69,33.11,,8.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.38,29.05,
HURRICAINE SPRAY 2OZ,293425,CDM,250,RC,,,Outpatient,,,32.29,19.37,,27.45,85,,21.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.38,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.84,80.03,,20.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.06,90,,23.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.38,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.29,,,,Other,Not Separately reimbursable,10.38,32.15,,8.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.42,88,,22.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.69,33.11,,8.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.38,29.06,
TRIDIL (NITROGLYCERIN) : 50MG INJ,293314,CDM,250,RC,,,Outpatient,,,32.45,19.47,,27.58,85,,22.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.97,80.03,,20.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.21,90,,23.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.45,,,,Other,Not Separately reimbursable,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.56,88,,22.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.74,33.11,,8.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.43,29.21,
DECADRON (DEXAMETH) 0.1% OCUMET. OPTH5ML,297750,CDM,250,RC,,,Outpatient,,,32.45,19.47,,27.58,85,,22.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.97,80.03,,20.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.21,90,,23.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.45,,,,Other,Not Separately reimbursable,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.56,88,,22.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.74,33.11,,8.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.43,29.21,
ANCEF (cefazolin) 500MG/SW 5ML PB,293287,CDM,636,RC,J0690,HCPCS,Outpatient,,,32.45,19.47,,27.58,85,,22.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.97,80.03,,20.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.21,90,,23.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.45,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.56,88,,22.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,29.21,
INOVAR INJ : 2ML,299023,CDM,636,RC,J1810,HCPCS,Outpatient,,,32.45,19.47,,27.58,85,,22.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.97,80.03,,20.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.21,90,,23.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.45,,,,Other,Not Separately reimbursable,10.43,32.15,,8.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.56,88,,22.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.74,33.11,,8.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.43,29.21,
DRESSING CUTIMED 2.75 X 3.35  HYDRO B,49293,CDM,270,RC,,,Outpatient,,,32.5,19.5,,27.63,85,,22.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.01,80.03,,20.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.25,90,,23.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.5,,,,Other,Not Separately reimbursable,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.6,88,,22.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.76,33.11,,8.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.45,29.25,
SPLINT FINGER 1 X 18,49703,CDM,270,RC,,,Outpatient,,,32.5,19.5,,27.63,85,,22.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.01,80.03,,20.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.25,90,,23.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.5,,,,Other,Not Separately reimbursable,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.6,88,,22.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.76,33.11,,8.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.45,29.25,
DRESSING MAXORB 1X12 FLAT ROPE AG,498016,CDM,270,RC,,,Outpatient,,,32.5,19.5,,27.63,85,,22.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.01,80.03,,20.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.25,90,,23.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.5,,,,Other,Not Separately reimbursable,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.6,88,,22.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.76,33.11,,8.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.45,29.25,
"ANTI-SCLERODERMA, SCI-70  (MAYO)",1886233,CDM,300,RC,86235,HCPCS,Outpatient,,,32.5,19.5,,27.63,85,,22.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.01,80.03,,20.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.25,90,,23.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.6,88,,22.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,29.25,
Blood test to determine existence of certain bacterium that causes syphilis,1886650,CDM,300,RC,86780,HCPCS,Outpatient,,,32.5,19.5,,27.63,85,,22.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.01,80.03,,20.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.25,90,,23.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.45,32.15,,8.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.6,88,,22.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.76,33.11,,8.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.45,29.25,
"TENHYDROXY CARBAMEZAPENE, TRILEPTOL MAYO",1882497,CDM,300,RC,80183,HCPCS,Outpatient,,,32.69,19.61,,27.79,85,,22.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.16,80.03,,20.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.42,90,,23.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.77,88,,23.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.47,29.42,
SPLINT FINGER 3/4 X 18,49702,CDM,270,RC,,,Outpatient,,,32.75,19.65,,27.84,85,,22.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.53,32.15,,8.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.21,80.03,,20.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.48,90,,23.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.53,32.15,,8.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.53,32.15,,8.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.82,88,,23.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.84,33.11,,8.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.53,29.48,
SPLINT FINGER 2 X 18,49704,CDM,270,RC,,,Outpatient,,,32.75,19.65,,27.84,85,,22.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.53,32.15,,8.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.21,80.03,,20.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.48,90,,23.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.53,32.15,,8.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.53,32.15,,8.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.82,88,,23.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.84,33.11,,8.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.53,29.48,
.HHN CIRCUIT,30135,CDM,270,RC,,,Outpatient,,,32.8,19.68,,27.88,85,,22.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.55,32.15,,8.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.25,80.03,,21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.52,90,,23.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.55,32.15,,8.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.55,32.15,,8.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.86,88,,23.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.86,33.11,,8.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.55,29.52,
BISMUTH SUBGALLATE POWDER DOSE,29312,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
MEDROL  DOSEPAK  (METHYLPREDNISOLONE),29360,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
ETHYL CHLORIDE 100%  SPRAY,292030,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
CATAPRES (clonidine) TTS-3 PATCH,292106,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
CLIMARA (ESTRADIOL) 0.1MG PATCH,292111,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
PHENERGAN (promethazine) 50MG SUPP,296045,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
MYCOSTATIN (nystatin) CREAM 15GM,297030,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
UREA 20% CREAM,297107,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
FLOSEAL ENDOSCOPIC APPLICATOR (reusable),297530,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
ALUM  (USP) POWDER 40GM,298026,CDM,250,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
NS (normal saline) 100ML,296300,CDM,258,RC,J7050,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.65,29.7,
ENEMA OIL,491032,CDM,270,RC,,,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
SOD CITRATE (ACD-FORMULA A) 5ML DIALYSIS,293190,CDM,272,RC,A4216,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
HIV SCREEN  SCH,1883892,CDM,300,RC,86701,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.7,29.7,
"URINE POTASSIUM, RANDOM",1884131,CDM,300,RC,84133,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.41,29.7,
MONO TEST QL,1886300,CDM,300,RC,86308,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,29.7,
"RHEUMATOID FACTOR, SERUM (MAYO)",1886430,CDM,300,RC,86431,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.14,29.7,
Blood test to screen for syphilis,1886592,CDM,300,RC,86592,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.65,29.7,
ADENOCARD (adenosine) 6MG/2ML SYRINGE,293124,CDM,636,RC,J0153,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.54,29.7,
ZINACEF (cefuroxime) 350MG /SW 4.7ML PB,293250,CDM,636,RC,J0697,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.87,29.7,
ZINACEF (cefuroxime): 750MG VIAL,293393,CDM,636,RC,J0697,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.87,29.7,
STADOL (butorphanol) 4MG / 2 ML INJ,293406,CDM,636,RC,J0595,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.62,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.54,29.7,
POT. CHLORIDE PB 10MEQ/100ML,293450,CDM,636,RC,J3480,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.11,29.7,
QUELICIN (SUCCINYL CHOLINE) 20MG/ML INJ,296047,CDM,636,RC,J0330,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.7,
DURAMORPH PF (morphine) 5MG / 10ML,299060,CDM,636,RC,J2270,HCPCS,Outpatient,,,33,19.8,,28.05,85,,22.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.41,80.03,,21.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.7,90,,23.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.04,88,,23.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,29.7,
SPECULA VAGINAL SMALL DISPOSABLE,49058,CDM,270,RC,,,Outpatient,,,33.01,19.81,,28.06,85,,22.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.42,80.03,,21.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.71,90,,23.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.61,32.15,,8.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.05,88,,23.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.93,33.11,,8.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.61,29.71,
Quantitative measure of glucose build up in the blood over time,11002,CDM,300,RC,82947,HCPCS,Outpatient,,,33.01,19.81,,28.06,85,,22.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.42,80.03,,21.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.71,90,,23.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.05,88,,23.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,29.71,
Quantitative measure of glucose build up in the blood over time,15001,CDM,300,RC,82947,HCPCS,Outpatient,,,33.01,19.81,,28.06,85,,22.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.42,80.03,,21.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.71,90,,23.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.05,88,,23.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,29.71,
Blood test to measure the amount of iron that is in transit in the body,1883545,CDM,300,RC,83540,HCPCS,Outpatient,,,33.01,19.81,,28.06,85,,22.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.42,80.03,,21.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,29.71,90,,23.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.05,88,,23.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.15,29.71,
KAYEXALATE 15G/60ML SORB. (SOD.POLYSTYRE,295112,CDM,250,RC,,,Outpatient,,,33.03,19.82,,28.08,85,,22.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.62,32.15,,8.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.43,80.03,,21.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.73,90,,23.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.62,32.15,,8.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.62,32.15,,8.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.07,88,,23.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.94,33.11,,8.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.62,29.73,
PLASTIBELL 1.1 - 1.7 CM CIRCUMCISION,498940,CDM,270,RC,,,Outpatient,,,33.06,19.84,,28.1,85,,22.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.63,32.15,,8.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.46,80.03,,21.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.75,90,,23.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.63,32.15,,8.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.63,32.15,,8.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.09,88,,23.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.95,33.11,,8.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.63,29.75,
D5W 100ML,296151,CDM,258,RC,J7060,HCPCS,Outpatient,,,33.2,19.92,,28.22,85,,22.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.57,80.03,,21.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.88,90,,23.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.22,88,,23.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.63,29.88,
D5W 250ML,296152,CDM,258,RC,J7060,HCPCS,Outpatient,,,33.2,19.92,,28.22,85,,22.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.57,80.03,,21.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.88,90,,23.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.22,88,,23.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.63,29.88,
NS (normal saline) :250ML,296291,CDM,258,RC,J7050,HCPCS,Outpatient,,,33.2,19.92,,28.22,85,,22.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.57,80.03,,21.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.88,90,,23.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.22,88,,23.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.65,29.88,
1/2 NS (half normal saline) :250ML,296292,CDM,258,RC,J7050,HCPCS,Outpatient,,,33.2,19.92,,28.22,85,,22.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.57,80.03,,21.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.88,90,,23.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.22,88,,23.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.65,29.88,
LEVSIN (hyoscyamine) 0.125MG/ML DROP 15M,294068,CDM,250,RC,,,Outpatient,,,33.22,19.93,,28.24,85,,22.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.68,32.15,,8.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.59,80.03,,21.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.9,90,,23.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.68,32.15,,8.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.68,32.15,,8.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.23,88,,23.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11,33.11,,8.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.68,29.9,
POLYTRIM (POLYMIX/TRIMETH)OPTH SOLN:10ML,297704,CDM,250,RC,,,Outpatient,,,33.22,19.93,,28.24,85,,22.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.68,32.15,,8.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.59,80.03,,21.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.9,90,,23.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.68,32.15,,8.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.68,32.15,,8.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.23,88,,23.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11,33.11,,8.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.68,29.9,
AMOXIL(AMOXICILLIN ) 400MG/5ML : 100ML,294015,CDM,250,RC,,,Outpatient,,,33.25,19.95,,28.26,85,,22.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.61,80.03,,21.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.93,90,,23.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.26,88,,23.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.01,33.11,,8.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.69,29.93,
SET FILTER LINE ADULT/PEDIATRIC,49089,CDM,270,RC,,,Outpatient,,,33.25,19.95,,28.26,85,,22.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.61,80.03,,21.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.93,90,,23.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.26,88,,23.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.01,33.11,,8.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.69,29.93,
HYDROGEL SKINTEGRITY 4OZ TUBE,498017,CDM,270,RC,,,Outpatient,,,33.25,19.95,,28.26,85,,22.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.61,80.03,,21.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.93,90,,23.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.69,32.15,,8.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.26,88,,23.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.01,33.11,,8.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.69,29.93,
IRRADIATION,1887817,CDM,300,RC,86945,HCPCS,Outpatient,,,33.25,19.95,,28.26,85,,22.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.61,80.03,,21.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,29.93,90,,23.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,36.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.26,88,,23.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.61,36.05,
ATROPINE: 1MG SYRINGE,293266,CDM,636,RC,J0461,HCPCS,Outpatient,,,33.33,20,,28.33,85,,22.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.67,80.03,,21.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30,90,,24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.33,88,,23.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,30,
ATROPINE (PED) : 0.25MG ABBJ,293510,CDM,636,RC,J0461,HCPCS,Outpatient,,,33.33,20,,28.33,85,,22.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.67,80.03,,21.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30,90,,24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.33,88,,23.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,30,
Injection to treat reaction to a drug,293037,CDM,636,RC,J0702,HCPCS,Outpatient,,,33.43,20.06,,28.42,85,,22.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.75,80.03,,21.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.09,90,,24.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.42,88,,23.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.41,30.09,
FOLVITE: 5MG/ML INJ,293086,CDM,250,RC,,,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.77,32.15,,8.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.77,32.15,,8.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.77,32.15,,8.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.09,33.11,,8.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.77,30.15,
"CALCIUM, 24HR URINE  (MAYO)",1882194,CDM,300,RC,82340,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.59,30.15,
"URINE CHLORIDE, 24HR",1882437,CDM,300,RC,82436,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,30.15,
"POTASSIUM, URINE 24HR",1884133,CDM,300,RC,84133,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.41,30.15,
"SODIUM, 24HR URINE",1884310,CDM,300,RC,84300,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.35,30.15,
HERPES SIMPLEX IGG TITER  (MAYO),1886693,CDM,300,RC,86694,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,30.15,
"INFLUENZA VIRUS A, IGG,IGM  (MAYO)",1886710,CDM,300,RC,86710,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.05,30.15,
"INFLUENZA VIRUS B, IGG,IGM  (MAYO)",1886711,CDM,300,RC,86710,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.05,30.15,
POT. CHLORIDE PB 40MEQ/ NS 250ML,293585,CDM,636,RC,J3480,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.11,30.15,
SANDOSTATIN (octreotide) 200MCG/ML *MDV*,296090,CDM,636,RC,J2354,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.12,30.15,
ZINACEF (cefuroxime)  750MG/ NS 50ML PB,302336,CDM,636,RC,J0697,HCPCS,Outpatient,,,33.5,20.1,,28.48,85,,22.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.81,80.03,,21.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.15,90,,24.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.48,88,,23.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.87,30.15,
NEOMYCIN PWDR,293296,CDM,250,RC,,,Outpatient,,,33.74,20.24,,28.68,85,,22.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27,80.03,,21.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.37,90,,24.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.69,88,,23.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.17,33.11,,8.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.85,30.37,
OCUFEN (FLURBIPROFEN) OPTH SOLN,297727,CDM,250,RC,,,Outpatient,,,33.74,20.24,,28.68,85,,22.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27,80.03,,21.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.37,90,,24.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.69,88,,23.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.17,33.11,,8.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.85,30.37,
ANCEF (cefazolin)  1GM/SW 10ML PB,293278,CDM,636,RC,J0690,HCPCS,Outpatient,,,33.74,20.24,,28.68,85,,22.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27,80.03,,21.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.37,90,,24.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.69,88,,23.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,30.37,
VALISONE (betamethasone) 0.1% CRM 15GM,297058,CDM,250,RC,,,Outpatient,,,33.75,20.25,,28.69,85,,22.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.01,80.03,,21.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.38,90,,24.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.85,32.15,,8.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.7,88,,23.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.17,33.11,,8.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.85,30.38,
"CITRATE EXCRETION, 24HR URINE  (MAYO)",1882199,CDM,300,RC,82507,HCPCS,Outpatient,,,33.75,20.25,,28.69,85,,22.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.01,80.03,,21.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.38,90,,24.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.7,88,,23.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.01,34.97,
"Q FEVER AB TITERS, PHASE I & II  (MAYO)",1886639,CDM,300,RC,86622,HCPCS,Outpatient,,,33.75,20.25,,28.69,85,,22.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.01,80.03,,21.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.38,90,,24.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.7,88,,23.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.23,30.38,
AKTEN (lidocaine )  3.5% OPTH GEL 1ML,297779,CDM,250,RC,,,Outpatient,,,33.9,20.34,,28.82,85,,23.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.9,32.15,,8.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.13,80.03,,21.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.51,90,,24.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.9,32.15,,8.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.9,32.15,,8.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.83,88,,23.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.22,33.11,,8.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.9,30.51,
TIMOPTIC (timolol) 0.5% OPTH 5ML,291065,CDM,250,RC,,,Outpatient,,,34,20.4,,28.9,85,,23.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.21,80.03,,21.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,90,,24.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.92,88,,23.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.26,33.11,,9.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.93,30.6,
DRESSING PURACOL PLUS 2 X 2 COLLAGEN,498025,CDM,272,RC,,,Outpatient,,,34,20.4,,28.9,85,,23.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.21,80.03,,21.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,90,,24.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.92,88,,23.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.26,33.11,,9.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.93,30.6,
Test of glucose level in the blood,1882937,CDM,300,RC,82950,HCPCS,Outpatient,,,34,20.4,,28.9,85,,23.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.21,80.03,,21.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.6,90,,24.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.92,88,,23.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,30.6,
Test of glucose level in the blood,1882938,CDM,300,RC,82950,HCPCS,Outpatient,,,34,20.4,,28.9,85,,23.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.21,80.03,,21.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.6,90,,24.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.92,88,,23.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,30.6,
"MUMPS AB, IGM  (MAYO)",1886268,CDM,300,RC,86735,HCPCS,Outpatient,,,34,20.4,,28.9,85,,23.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.21,80.03,,21.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.31,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.6,90,,24.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.31,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.92,88,,23.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.41,30.6,
NORFLEX (orphenadrine) 60MG/2ML INJ,293128,CDM,636,RC,J2360,HCPCS,Outpatient,,,34,20.4,,28.9,85,,23.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.21,80.03,,21.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,90,,24.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.92,88,,23.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.67,30.6,
CEREBYX (FOSphenytoin) 100MG/2ML INJ,293485,CDM,636,RC,Q2009,HCPCS,Outpatient,,,34,20.4,,28.9,85,,23.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.21,80.03,,21.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,90,,24.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.93,32.15,,8.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.92,88,,23.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.26,33.11,,9.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,10.93,30.6,
"Blood test, clotting time",1885610,CDM,300,RC,85610,HCPCS,Outpatient,,,34.03,20.42,,28.93,85,,23.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.23,80.03,,21.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.37,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.63,90,,24.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.37,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.95,88,,23.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.94,30.63,
Coagulation assessment blood test,1885730,CDM,300,RC,85730,HCPCS,Outpatient,,,34.03,20.42,,28.93,85,,23.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.23,80.03,,21.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.63,90,,24.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.95,88,,23.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.54,30.63,
SHIGA TOXIN,1887899,CDM,300,RC,87899,HCPCS,Outpatient,,,34.03,20.42,,28.93,85,,23.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.23,80.03,,21.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.63,90,,24.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.95,88,,23.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,30.63,
OXYGEN TRANSPORT,30019,CDM,412,RC,,,Outpatient,,,34.2,20.52,,29.07,85,,23.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11,32.15,,8.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.37,80.03,,21.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,90,,24.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11,32.15,,8.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11,32.15,,8.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.1,88,,24.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.32,33.11,,9.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11,30.78,
HALDOL (HALOPERIDOL) 2MG/ML : SOLN 15ML,295040,CDM,250,RC,,,Outpatient,,,34.25,20.55,,29.11,85,,23.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.01,32.15,,8.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.41,80.03,,21.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.83,90,,24.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.01,32.15,,8.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.01,32.15,,8.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.14,88,,24.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.34,33.11,,9.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.01,30.83,
NS (normal saline) 50ML,296299,CDM,258,RC,J7050,HCPCS,Outpatient,,,34.25,20.55,,29.11,85,,23.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.41,80.03,,21.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.83,90,,24.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.14,88,,24.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.65,30.83,
BELT TRANSDUCER W/VELCRO XL,492113,CDM,270,RC,,,Outpatient,,,34.25,20.55,,29.11,85,,23.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.01,32.15,,8.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.41,80.03,,21.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.83,90,,24.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.01,32.15,,8.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.01,32.15,,8.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.14,88,,24.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.34,33.11,,9.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.01,30.83,
".INSULIN, FREE SERUM  (MAYO)",1882213,CDM,300,RC,83527,HCPCS,Outpatient,,,34.25,20.55,,29.11,85,,23.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.41,80.03,,21.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.83,90,,24.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.14,88,,24.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,30.83,
CERULOPLASMIN  (MAYO),1882390,CDM,300,RC,82390,HCPCS,Outpatient,,,34.25,20.55,,29.11,85,,23.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.41,80.03,,21.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,30.83,90,,24.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.14,88,,24.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.51,30.83,
ZINACEF (cefuroxime)  1.5GM/ NS 100ML PB,302337,CDM,636,RC,J0697,HCPCS,Outpatient,,,34.33,20.6,,29.18,85,,23.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.47,80.03,,21.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.9,90,,24.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.21,88,,24.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.87,30.9,
"POLYMYXIN B 500,000UNITS INJ",297524,CDM,250,RC,,,Outpatient,,,34.35,20.61,,29.2,85,,23.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.04,32.15,,8.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.49,80.03,,21.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.92,90,,24.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.04,32.15,,8.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.04,32.15,,8.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.23,88,,24.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.37,33.11,,9.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.04,30.92,
CREAM ANTIFUNGAL REMEDY 4 OZ,498018,CDM,270,RC,,,Outpatient,,,34.38,20.63,,29.22,85,,23.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.05,32.15,,8.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.51,80.03,,22.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.94,90,,24.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.05,32.15,,8.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.05,32.15,,8.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.25,88,,24.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.38,33.11,,9.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.05,30.94,
LIPASE,1883690,CDM,300,RC,83690,HCPCS,Outpatient,,,34.45,20.67,,29.28,85,,23.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.57,80.03,,22.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.01,90,,24.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.32,88,,24.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.66,31.01,
MASK ANESTHESIA CHILD SMALL SIZE 3,491583,CDM,270,RC,,,Outpatient,,,34.5,20.7,,29.33,85,,23.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.61,80.03,,22.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.05,90,,24.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.36,88,,24.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.42,33.11,,9.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.09,31.05,
SIGMOIDSCOPE 19MMX25CM,493016,CDM,270,RC,,,Outpatient,,,34.5,20.7,,29.33,85,,23.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.61,80.03,,22.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.05,90,,24.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.36,88,,24.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.42,33.11,,9.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.09,31.05,
SICKLE CELL TEST,1887818,CDM,300,RC,85660,HCPCS,Outpatient,,,34.5,20.7,,29.33,85,,23.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.61,80.03,,22.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.05,90,,24.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.36,88,,24.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.94,31.05,
TOUCH PREP ADDITIONAL,2188334,CDM,310,RC,88333,HCPCS,Outpatient,,,34.5,20.7,,29.33,85,,23.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.61,80.03,,22.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,31.05,90,,24.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.36,88,,24.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.61,75.49,
MISC DRUG 30,29912,CDM,250,RC,,,Outpatient,,,34.51,20.71,,29.33,85,,23.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.62,80.03,,22.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.06,90,,24.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.09,32.15,,8.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.37,88,,24.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.43,33.11,,9.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.09,31.06,
VANCOMYCIN 750MG /150ML PREMIXED IVPB,304010,CDM,636,RC,J3370,HCPCS,Outpatient,,,34.56,20.74,,29.38,85,,23.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.66,80.03,,22.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.1,90,,24.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.41,88,,24.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,31.1,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",593015,CDM,430,RC,97016,HCPCS,Outpatient,,,34.7,20.82,,29.5,85,,23.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.16,32.15,,8.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.77,80.03,,22.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.44,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,31.23,90,,24.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.16,32.15,,8.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,11.16,32.15,,8.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.54,88,,24.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.49,33.11,,9.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.16,31.23,
Use of massage,593038,CDM,430,RC,97124,HCPCS,Outpatient,,,34.7,20.82,,29.5,85,,23.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.16,32.15,,8.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.77,80.03,,22.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,31.23,90,,24.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.16,32.15,,8.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,11.16,32.15,,8.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.54,88,,24.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.49,33.11,,9.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.16,31.23,
BACTRIM (SULFAMETH/TRIMETH) SUSP: 100ML,294005,CDM,250,RC,,,Outpatient,,,34.77,20.86,,29.55,85,,23.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.83,80.03,,22.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.29,90,,25.03,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.6,88,,24.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.51,33.11,,9.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.18,31.29,
PROSTIN (DINOPROSTONE) 2MG SUPP,296105,CDM,250,RC,,,Outpatient,,,34.77,20.86,,29.55,85,,23.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.83,80.03,,22.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.29,90,,25.03,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.6,88,,24.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.51,33.11,,9.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.18,31.29,
CORTISPORIN OPHTH OINT 3.5 G,297503,CDM,250,RC,,,Outpatient,,,34.77,20.86,,29.55,85,,23.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.83,80.03,,22.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.29,90,,25.03,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.6,88,,24.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.51,33.11,,9.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.18,31.29,
TIMOPTIC GFS (TIMOLOL) 0.5% OPTH GEL 5ML,297769,CDM,250,RC,,,Outpatient,,,34.77,20.86,,29.55,85,,23.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.83,80.03,,22.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.29,90,,25.03,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.18,32.15,,8.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.6,88,,24.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.51,33.11,,9.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.18,31.29,
RETICULOCYTE COUNT,1885044,CDM,300,RC,85045,HCPCS,Outpatient,,,34.85,20.91,,29.62,85,,23.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.89,80.03,,22.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.37,90,,25.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.67,88,,24.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.03,31.37,
XYLOCAINE 2% JELLY 30MLTUBE,297094,CDM,250,RC,,,Outpatient,,,34.87,20.92,,29.64,85,,23.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.21,32.15,,8.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,27.91,80.03,,22.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.38,90,,25.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.21,32.15,,8.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.21,32.15,,8.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.69,88,,24.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.55,33.11,,9.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.21,31.38,
CARAFATE (sucralfate) 1GM/10ML SUSP :1OZ,292328,CDM,250,RC,,,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
ZANTAC (ranitidine)  50MG /SW 10ML PB,293290,CDM,250,RC,,,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
ZANTAC NEW TEST,293900,CDM,250,RC,,,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
KENALOG CRM (triamcinolone) 0.1%  80GM,297080,CDM,250,RC,,,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
RID (piperonyl/pyrethrin) SHAMPOO 4OZ,298037,CDM,250,RC,,,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
VENTILATOR SET/TRAAVENOL 8,30245,CDM,270,RC,94799,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
**DO NOT USE**  P/T DEBRIDEMENT II,311206,CDM,270,RC,,,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
Quantitative measure of glucose build up in the blood over time,1882949,CDM,300,RC,82947,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,31.5,
"GLUCOSE, URINE QL",1882954,CDM,300,RC,82945,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,31.5,
Quantitative measure of glucose build up in the blood over time,1882958,CDM,300,RC,82947,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,31.5,
Blood test to evaluate thyroid function,1884481,CDM,300,RC,84480,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.46,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.46,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.03,31.5,
"O&P DIRECT SMEARS, CONC&ID  (MAYO)",1887178,CDM,300,RC,87177,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.07,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.07,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.19,31.5,
..PIN WORM PREP,1887208,CDM,300,RC,87172,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.36,31.5,
Form of decompression therapy of the spine,311006,CDM,420,RC,97012,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
Therapy for speech or hearing,31133,CDM,440,RC,92507,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
KYTRIL (granisetron) 0.1mg/ml SDV,29663,CDM,636,RC,J1626,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.4,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.39,31.5,
KYTRIL (granisetron) 1MG TAB,29742,CDM,636,RC,Q0166,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.25,32.15,,9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.59,33.11,,9.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.25,31.5,
KYTRIL (granisetron) *1MG/ml* SDV,292133,CDM,636,RC,J1626,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.4,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.39,31.5,
ROCEPHIN (ceftriaxone) 2GM / NS 100ML PB,300167,CDM,636,RC,J0696,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.47,31.5,
GENTAMICIN 100 MG/50ML NS IVPB,300170,CDM,636,RC,J1580,HCPCS,Outpatient,,,35,21,,29.75,85,,23.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.01,80.03,,22.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,90,,25.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.8,88,,24.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,31.5,
Quantitative measure of glucose build up in the blood over time,1882940,CDM,300,RC,82947,HCPCS,Outpatient,,,35.25,21.15,,29.96,85,,23.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.21,80.03,,22.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.73,90,,25.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.02,88,,24.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,31.73,
APOLIPOPROTEIN B-100  (MAYO),1883702,CDM,300,RC,82172,HCPCS,Outpatient,,,35.25,21.15,,29.96,85,,23.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.21,80.03,,22.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,31.73,90,,25.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.02,88,,24.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.49,31.73,
BRONKSOL : 10ML,292035,CDM,250,RC,,,Outpatient,,,35.28,21.17,,29.99,85,,23.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.23,80.03,,22.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.75,90,,25.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.05,88,,24.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,33.11,,9.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.34,31.75,
LEVOPROME 20MG/ML INJ,293099,CDM,250,RC,,,Outpatient,,,35.28,21.17,,29.99,85,,23.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.23,80.03,,22.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.75,90,,25.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.05,88,,24.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,33.11,,9.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.34,31.75,
NORCURON (INACTIVE),293292,CDM,250,RC,,,Outpatient,,,35.28,21.17,,29.99,85,,23.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.23,80.03,,22.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.75,90,,25.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.05,88,,24.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,33.11,,9.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.34,31.75,
BACTROBAN (mupirocin) 2% OINT 22 GRAM,297085,CDM,250,RC,,,Outpatient,,,35.28,21.17,,29.99,85,,23.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.23,80.03,,22.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.75,90,,25.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.05,88,,24.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,33.11,,9.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.34,31.75,
DOMEBORO OTIC SOL 60ML,297807,CDM,250,RC,,,Outpatient,,,35.28,21.17,,29.99,85,,23.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.23,80.03,,22.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.75,90,,25.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.05,88,,24.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,33.11,,9.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.34,31.75,
DELESTROGEN 20MG/ML INJ,293057,CDM,636,RC,J1380,HCPCS,Outpatient,,,35.28,21.17,,29.99,85,,23.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.23,80.03,,22.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.75,90,,25.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.34,32.15,,9.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.05,88,,24.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,33.11,,9.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.34,31.75,
FLU VACCINE PEDIATRIC PF 0.25 ML,293529,CDM,636,RC,Q2038,HCPCS,Outpatient,,,35.3,21.18,,30.01,85,,24.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.35,32.15,,9.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.25,80.03,,22.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.77,90,,25.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.35,32.15,,9.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.35,32.15,,9.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.06,88,,24.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.69,33.11,,9.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.35,31.77,
CATHETER FOLLOWER HEYMAN 16FR STRT TIP,49412,CDM,270,RC,,,Outpatient,,,35.5,21.3,,30.18,85,,24.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.41,32.15,,9.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.41,80.03,,22.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.95,90,,25.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.41,32.15,,9.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.41,32.15,,9.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.24,88,,24.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.75,33.11,,9.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.41,31.95,
DIAPERS SZ 3 CRAWLER 16-28  LBS,49876,CDM,270,RC,,,Outpatient,,,35.75,21.45,,30.39,85,,24.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.49,32.15,,9.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.61,80.03,,22.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.18,90,,25.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.49,32.15,,9.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.49,32.15,,9.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.46,88,,25.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.84,33.11,,9.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.49,32.18,
SET MICROBORE EXTENSION 60,496474,CDM,270,RC,,,Outpatient,,,35.75,21.45,,30.39,85,,24.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.49,32.15,,9.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.61,80.03,,22.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.18,90,,25.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.49,32.15,,9.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.49,32.15,,9.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.46,88,,25.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.84,33.11,,9.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.49,32.18,
"URIC ACID, 24HR URINE  (MAYO)",1882202,CDM,300,RC,84560,HCPCS,Outpatient,,,35.75,21.45,,30.39,85,,24.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.61,80.03,,22.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.18,90,,25.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.46,88,,25.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,32.18,
"UREA NITROGEN, 24HR URINE",1884540,CDM,300,RC,84540,HCPCS,Outpatient,,,35.75,21.45,,30.39,85,,24.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.61,80.03,,22.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.18,90,,25.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.46,88,,25.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,32.18,
"UREA NITROGEN URINE,(MAYO)RANDOM",1884541,CDM,300,RC,84540,HCPCS,Outpatient,,,35.75,21.45,,30.39,85,,24.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.61,80.03,,22.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.18,90,,25.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.46,88,,25.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,32.18,
ZYPREXA (olanzapine) 10MG TAB,29644,CDM,250,RC,,,Outpatient,,,35.8,21.48,,30.43,85,,24.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.65,80.03,,22.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.22,90,,25.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,88,,25.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.85,33.11,,9.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.51,32.22,
AMICAR INJ : 250MG/ML  20ML,293007,CDM,250,RC,,,Outpatient,,,35.8,21.48,,30.43,85,,24.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.65,80.03,,22.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.22,90,,25.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,88,,25.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.85,33.11,,9.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.51,32.22,
PROSTIGMIN (NEOSTIGMINE) 1/4000 INJ,293151,CDM,250,RC,,,Outpatient,,,35.8,21.48,,30.43,85,,24.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.65,80.03,,22.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.22,90,,25.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,88,,25.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.85,33.11,,9.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.51,32.22,
"WYCILLIN (pen G procaine)2,400,000 units",296069,CDM,250,RC,,,Outpatient,,,35.8,21.48,,30.43,85,,24.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.65,80.03,,22.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.22,90,,25.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,88,,25.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.85,33.11,,9.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.51,32.22,
TRIAMCIN 0.1% /HYDROPHILIC OINT 454GM,297092,CDM,250,RC,,,Outpatient,,,35.8,21.48,,30.43,85,,24.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.65,80.03,,22.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.22,90,,25.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,88,,25.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.85,33.11,,9.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.51,32.22,
NEOSPORIN (BACI/NEO/POLYMIX) OPTH SOLN,297725,CDM,250,RC,,,Outpatient,,,35.8,21.48,,30.43,85,,24.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.65,80.03,,22.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.22,90,,25.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.51,32.15,,9.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.5,88,,25.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.85,33.11,,9.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.51,32.22,
CLEOCIN  (clindamycin) 900MG/NS 100ML,301800,CDM,250,RC,S0077,HCPCS,Outpatient,,,35.87,21.52,,30.49,85,,24.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.53,32.15,,9.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.71,80.03,,22.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.28,90,,25.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.53,32.15,,9.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.53,32.15,,9.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.57,88,,25.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.88,33.11,,9.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.53,32.28,
HEEL INCISION DEVICE 1.0MM,491558,CDM,270,RC,,,Outpatient,,,35.88,21.53,,30.5,85,,24.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.54,32.15,,9.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.71,80.03,,22.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.29,90,,25.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.54,32.15,,9.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.54,32.15,,9.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.57,88,,25.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.88,33.11,,9.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.54,32.29,
GENTAMICIN 10 MG/ML INJ 2ML VIAL (PED),293087,CDM,250,RC,,,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.92,33.11,,9.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.57,32.4,
BRONCHOSCOPY ADAPTER,13050,CDM,270,RC,,,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.92,33.11,,9.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.57,32.4,
BREATHING CIRCUIT DISP,13075,CDM,270,RC,,,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.92,33.11,,9.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.57,32.4,
CATHETER FOLEY 20FR 30ML SILVER / HYDROG,49535,CDM,270,RC,,,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.92,33.11,,9.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.57,32.4,
DRESSING PRISMA MATRIX 4.34 SQ IN,498029,CDM,272,RC,,,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.92,33.11,,9.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.57,32.4,
URINE CALCIUM (RANDOM) (MAYO),1882342,CDM,300,RC,82340,HCPCS,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.59,32.4,
GAMMA GT (GGT),1882977,CDM,300,RC,82977,HCPCS,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,32.4,
SUBLIMAZE (fentanyl) 50ML VIAL- RX USE,299066,CDM,636,RC,J3010,HCPCS,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,32.4,
KEPPRA (levetiracetam) 500MG/5ML VIAL,304577,CDM,636,RC,J1953,HCPCS,Outpatient,,,36,21.6,,30.6,85,,24.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.81,80.03,,23.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.4,90,,25.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36,,,,Other,Not Separately reimbursable,11.57,32.15,,9.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.68,88,,25.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.92,33.11,,9.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.57,32.4,
POLYSPORIN (BACI/POLYMIX) OPTH OINT:3.5G,297511,CDM,250,RC,,,Outpatient,,,36.1,21.66,,30.69,85,,24.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.61,32.15,,9.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,80.03,,23.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.49,90,,25.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.61,32.15,,9.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.1,,,,Other,Not Separately reimbursable,11.61,32.15,,9.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.77,88,,25.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.95,33.11,,9.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.61,32.49,
ATTACHMENT PLATE LEG,4912006,CDM,270,RC,,,Outpatient,,,36.25,21.75,,30.81,85,,24.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.65,32.15,,9.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.01,80.03,,23.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.63,90,,26.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.65,32.15,,9.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.25,,,,Other,Not Separately reimbursable,11.65,32.15,,9.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.9,88,,25.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12,33.11,,9.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.65,32.63,
"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",1880004,CDM,300,RC,80051,HCPCS,Outpatient,,,36.25,21.75,,30.81,85,,24.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.01,80.03,,23.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.63,90,,26.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.9,88,,25.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.82,32.63,
AMYLASE,1882150,CDM,300,RC,82150,HCPCS,Outpatient,,,36.25,21.75,,30.81,85,,24.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.01,80.03,,23.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.63,90,,26.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.9,88,,25.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.15,32.63,
INSULIN  (MAYO),1883525,CDM,300,RC,83525,HCPCS,Outpatient,,,36.25,21.75,,30.81,85,,24.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.01,80.03,,23.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.63,90,,26.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.9,88,,25.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.38,32.63,
FETAL SCREEN,2085461,CDM,300,RC,85461,HCPCS,Outpatient,,,36.25,21.75,,30.81,85,,24.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.01,80.03,,23.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.54,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.63,90,,26.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.54,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.9,88,,25.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.33,32.63,
PENICILLIN : 5 MILL UNITS VIAL,293369,CDM,636,RC,J2510,HCPCS,Outpatient,,,36.45,21.87,,30.98,85,,24.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.72,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.17,80.03,,23.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,32.81,90,,26.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.72,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,11.72,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.08,88,,25.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.07,33.11,,9.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.72,32.81,
RESTRAINT WRIST,491300,CDM,270,RC,,,Outpatient,,,36.49,21.89,,31.02,85,,24.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.2,80.03,,23.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.84,90,,26.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.49,,,,Other,Not Separately reimbursable,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.11,88,,25.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.08,33.11,,9.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.73,32.84,
CLEOCIN 75MG/5ML PEDIATRIC SUSP 100 ML,294013,CDM,250,RC,,,Outpatient,,,36.5,21.9,,31.03,85,,24.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.21,80.03,,23.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.85,90,,26.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.5,,,,Other,Not Separately reimbursable,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.12,88,,25.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.09,33.11,,9.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.73,32.85,
PAD OPTIFLEX,49054,CDM,270,RC,,,Outpatient,,,36.5,21.9,,31.03,85,,24.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.21,80.03,,23.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.85,90,,26.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.5,,,,Other,Not Separately reimbursable,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.12,88,,25.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.09,33.11,,9.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.73,32.85,
STICK BITE,49180,CDM,270,RC,,,Outpatient,,,36.5,21.9,,31.03,85,,24.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.21,80.03,,23.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.85,90,,26.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.5,,,,Other,Not Separately reimbursable,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.12,88,,25.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.09,33.11,,9.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.73,32.85,
SET ENEMA ADMINISTRATION,492028,CDM,270,RC,,,Outpatient,,,36.5,21.9,,31.03,85,,24.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.21,80.03,,23.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.85,90,,26.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.5,,,,Other,Not Separately reimbursable,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.12,88,,25.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.09,33.11,,9.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.73,32.85,
SWABSTICK PREVANTICS 1.6ML,493968,CDM,270,RC,,,Outpatient,,,36.5,21.9,,31.03,85,,24.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.21,80.03,,23.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.85,90,,26.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.5,,,,Other,Not Separately reimbursable,11.73,32.15,,9.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.12,88,,25.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.09,33.11,,9.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.73,32.85,
"ANTI-MICROSOMAL, LIVER/KIDNEY  (MAYO)",1886256,CDM,300,RC,86376,HCPCS,Outpatient,,,36.5,21.9,,31.03,85,,24.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.21,80.03,,23.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,32.85,90,,26.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.12,88,,25.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.3,32.85,
UNIPEN  (nafcillin) 1GM /NS 50ML PB,293200,CDM,250,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.57,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
WYAMINE S04 30MG/ML INJ,293212,CDM,250,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.57,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
ACETIC ACID 0.25% IRRIGATION 1000ML,296533,CDM,250,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.57,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
NS IRG  500ML,296534,CDM,250,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
STERILE WATER: INJ 1000ML,296010,CDM,258,RC,A4217,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.5,32.91,
D5W: 500ML BTL,296156,CDM,258,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D5W 1000ML,296162,CDM,258,RC,J7070,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.36,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.26,32.91,
D5 1/4NS 500 ML,296180,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 1/4NS 1000 ML,296182,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 1/3NS  500 ML,296192,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 1/3NS 1000 ML,296193,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 1/2 NS   250ML,296194,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 1/3 NS   250ML,296195,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 1/4NS 250ML,296196,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D 2.5% 1/2NS  1000ML,296199,CDM,258,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D5 1/2 NS  500ML,296205,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 1/2 NS 1000ML,296206,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5NS 500ML,296212,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5NS 1000ML,296218,CDM,258,RC,J7042,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,32.91,
D5 LR 500ML,296224,CDM,258,RC,S5011,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D5 LR 1000ML,296230,CDM,258,RC,S5011,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D10W 500ML,296235,CDM,258,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D10W 1000ML,296236,CDM,258,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D20W 1000ML,296239,CDM,258,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D50W: 500ML/1000ML,296243,CDM,258,RC,J7060,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.63,32.91,
LR (lactated ringers) :1000ML,296254,CDM,258,RC,J7120,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.45,32.91,
NS: 500ML BTL,296289,CDM,258,RC,J7040,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.29,32.91,
SOD CHLOR 0.45%  500ML,296301,CDM,258,RC,J7030,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.58,32.91,
1/2 NS (SOD CHLOR 0.45%  1000ML),296314,CDM,258,RC,J7030,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.58,32.91,
SOD CHLORIDE 3%: 500ML,296319,CDM,258,RC,J7131,HCPCS,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
STER WATER IRG 500ML,296552,CDM,258,RC,,,Outpatient,,,36.57,21.94,,31.08,85,,24.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.27,80.03,,23.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.91,90,,26.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.76,32.15,,9.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.18,88,,25.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.11,33.11,,9.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.76,32.91,
D10W 250ML,296241,CDM,258,RC,,,Outpatient,,,36.6,21.96,,31.11,85,,24.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.77,32.15,,9.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.29,80.03,,23.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.94,90,,26.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.77,32.15,,9.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.77,32.15,,9.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.21,88,,25.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.12,33.11,,9.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.77,32.94,
SOD CHLOR 0.45% + 20 MEQ KCL 1000 ML,296315,CDM,258,RC,J7030,HCPCS,Outpatient,,,36.6,21.96,,31.11,85,,24.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.29,80.03,,23.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.94,90,,26.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,88,,25.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.58,32.94,
SPECIMEN TRAP 40CC W/CAP,49769,CDM,270,RC,,,Outpatient,,,36.7,22.02,,31.2,85,,24.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.8,32.15,,9.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.37,80.03,,23.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.03,90,,26.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.8,32.15,,9.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.8,32.15,,9.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.3,88,,25.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.15,33.11,,9.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.8,33.03,
NEBCIN DOSING per Pharmacy,293501,CDM,250,RC,J3260,HCPCS,Outpatient,,,36.75,22.05,,31.24,85,,24.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.41,80.03,,23.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.08,90,,26.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.34,88,,25.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.65,33.08,
"...MYOGLOBIN, URINE  (MAYO)",1883875,CDM,300,RC,83874,HCPCS,Outpatient,,,36.75,22.05,,31.24,85,,24.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.41,80.03,,23.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.17,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.08,90,,26.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.17,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.34,88,,25.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.24,33.08,
TOXOPLASMA  AB SCREEN  (MAYO),1886253,CDM,300,RC,86777,HCPCS,Outpatient,,,36.75,22.05,,31.24,85,,24.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.41,80.03,,23.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.08,90,,26.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.34,88,,25.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,33.08,
..FUNGAL SMEAR (MAYO),1887200,CDM,300,RC,87206,HCPCS,Outpatient,,,36.75,22.05,,31.24,85,,24.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.41,80.03,,23.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.08,90,,26.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.34,88,,25.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,33.08,
CROSSMATCH LEUKO-REDUCED,2086077,CDM,390,RC,86904,HCPCS,Outpatient,,,36.75,22.05,,31.24,85,,24.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.41,80.03,,23.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,33.08,90,,26.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,11.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.34,88,,25.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.31,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.95,33.08,
"OASIS WOUND MATRIX, PER 1 SQ CM",844102,CDM,636,RC,Q4102,HCPCS,Outpatient,,,36.75,22.05,,31.24,85,,24.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.82,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.41,80.03,,23.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.08,90,,26.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.82,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.82,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.34,88,,25.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.17,33.11,,9.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.82,33.08,
P/T DEBRIDEMENT(S),3901,CDM,420,RC,97799,HCPCS,Outpatient,,,36.8,22.08,,31.28,85,,25.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.83,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.45,80.03,,23.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.12,90,,26.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.83,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.83,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.38,88,,25.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.18,33.11,,9.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.83,33.12,
BANDAGE ACE 6,53132,CDM,540,RC,,,Outpatient,,,36.8,22.08,,31.28,85,,25.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.83,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.45,80.03,,23.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.12,90,,26.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.83,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.83,32.15,,9.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.38,88,,25.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.18,33.11,,9.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.83,33.12,
STRAPS MONTGOMERY,493298,CDM,270,RC,,,Outpatient,,,37,22.2,,31.45,85,,25.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.61,80.03,,23.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.3,90,,26.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.56,88,,26.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.25,33.11,,9.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.9,33.3,
SMOKING CESSATION COUNCELING (3-10 MIN),422,CDM,942,RC,99406,HCPCS,Outpatient,,,37,22.2,,31.45,85,,25.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.61,80.03,,23.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.44,102,,,fee schedule,Pays at 102% of CMS APC rate,33.3,90,,26.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.44,100,,,fee schedule,Pays at 100% of CMS APC rate,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.56,88,,26.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.25,33.11,,9.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.9,33.3,
SMOKING CESSATION COUNCELING (>10 MIN),447,CDM,942,RC,99407,HCPCS,Outpatient,,,37,22.2,,31.45,85,,25.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.61,80.03,,23.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.44,102,,,fee schedule,Pays at 102% of CMS APC rate,33.3,90,,26.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.44,100,,,fee schedule,Pays at 100% of CMS APC rate,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.56,88,,26.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.25,33.11,,9.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.9,33.3,
MANTADIL CREAM 15GM,297038,CDM,250,RC,,,Outpatient,,,37.08,22.25,,31.52,85,,25.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.68,80.03,,23.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.37,90,,26.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.63,88,,26.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.28,33.11,,9.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.92,33.37,
CERUMENEX OTIC DROPS 6ML,297803,CDM,250,RC,,,Outpatient,,,37.08,22.25,,31.52,85,,25.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.68,80.03,,23.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.37,90,,26.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.63,88,,26.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.28,33.11,,9.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.92,33.37,
BETAGAN C OPTH 5% 5ML,2957808,CDM,250,RC,,,Outpatient,,,37.08,22.25,,31.52,85,,25.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.68,80.03,,23.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.37,90,,26.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.63,88,,26.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.28,33.11,,9.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.92,33.37,
TAMIFLU (oseltamivir) 75 MG CAP,29860,CDM,250,RC,,,Outpatient,,,37.09,22.25,,31.53,85,,25.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.68,80.03,,23.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.38,90,,26.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.92,32.15,,9.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.64,88,,26.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.28,33.11,,9.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.92,33.38,
PAD DEFIB CHILD,491018,CDM,270,RC,,,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.33,33.11,,9.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.98,33.53,
PAD DEFIB ADULT,491019,CDM,270,RC,,,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.33,33.11,,9.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.98,33.53,
PLASTIBELL 1.1 CM CIRCUMCISION,498941,CDM,270,RC,,,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.33,33.11,,9.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.98,33.53,
PLASTIBELL 1.2 CM CIRCUMCISION,498942,CDM,270,RC,,,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.98,32.15,,9.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.33,33.11,,9.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.98,33.53,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1883530,CDM,300,RC,83516,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,33.53,
"VITAMIN A, SERUM  (MAYO)",1884590,CDM,300,RC,84590,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.58,33.53,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1886255,CDM,300,RC,83516,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,33.53,
HEPATITIS BE AG  (MAYO),1886293,CDM,300,RC,87350,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.49,33.53,
HEPATITIS BE AB  (MAYO),1886707,CDM,300,RC,86707,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.8,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.8,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.54,33.53,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,1887046,CDM,300,RC,87046,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.97,33.53,
BETA LACTAMASE,1887183,CDM,300,RC,87185,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,33.53,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1889001,CDM,300,RC,83516,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,33.53,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1889002,CDM,300,RC,83516,HCPCS,Outpatient,,,37.25,22.35,,31.66,85,,25.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.81,80.03,,23.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.53,90,,26.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.78,88,,26.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,33.53,
"Complete blood count, automated",1885021,CDM,300,RC,85027,HCPCS,Outpatient,,,37.31,22.39,,31.71,85,,25.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.86,80.03,,23.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.58,90,,26.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.83,88,,26.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.14,33.58,
MEGACE (MEGESTROL) 40MG/ML SUSP: 1OZ,295020,CDM,250,RC,,,Outpatient,,,37.39,22.43,,31.78,85,,25.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.02,32.15,,9.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.92,80.03,,23.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.65,90,,26.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.02,32.15,,9.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.02,32.15,,9.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.9,88,,26.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.38,33.11,,9.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.02,33.65,
.AEROSOL TUBE,30140,CDM,270,RC,,,Outpatient,,,37.5,22.5,,31.88,85,,25.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.06,32.15,,9.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.01,80.03,,24.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.75,90,,27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.06,32.15,,9.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.06,32.15,,9.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33,88,,26.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.42,33.11,,9.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.06,33.75,
DRAPE STERI 1000 17  X 11,4960980,CDM,270,RC,,,Outpatient,,,37.5,22.5,,31.88,85,,25.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.06,32.15,,9.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.01,80.03,,24.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.75,90,,27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.06,32.15,,9.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.06,32.15,,9.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33,88,,26.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.42,33.11,,9.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.06,33.75,
DOPAMINE 400/250ML DRIP,296111,CDM,258,RC,J1265,HCPCS,Outpatient,,,37.53,22.52,,31.9,85,,25.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.07,32.15,,9.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.04,80.03,,24.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.78,90,,27.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.07,32.15,,9.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.07,32.15,,9.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.03,88,,26.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.43,33.11,,9.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.07,33.78,
Blood test to assess for pregnancy,1884703,CDM,300,RC,84703,HCPCS,Outpatient,,,37.6,22.56,,31.96,85,,25.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.09,80.03,,24.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.84,90,,27.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.09,88,,26.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.31,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.07,33.84,
CLAFORAN  (cefotaxime) 500MG /SW 5ML PB,293247,CDM,636,RC,J0698,HCPCS,Outpatient,,,37.6,22.56,,31.96,85,,25.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.09,80.03,,24.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.84,90,,27.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.09,88,,26.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.8,33.84,
ABILIFY (aripiprazole) 20MG TAB,291093,CDM,250,RC,,,Outpatient,,,37.7,22.62,,32.05,85,,25.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.12,32.15,,9.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.17,80.03,,24.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.93,90,,27.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.12,32.15,,9.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.12,32.15,,9.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.18,88,,26.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.48,33.11,,9.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.12,33.93,
CYCLOSPORINE BLOOD   MAYO,1880035,CDM,300,RC,80158,HCPCS,Outpatient,,,37.75,22.65,,32.09,85,,25.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.21,80.03,,24.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.41,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.98,90,,27.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.22,88,,26.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.5,33.98,
AMIODARONE   (MAYO),1880037,CDM,300,RC,80299,HCPCS,Outpatient,,,37.75,22.65,,32.09,85,,25.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.21,80.03,,24.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.98,90,,27.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.22,88,,26.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,33.98,
ACID PHOSPHATASE PROSTAT  (MAYO),1884060,CDM,300,RC,84066,HCPCS,Outpatient,,,37.75,22.65,,32.09,85,,25.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.21,80.03,,24.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.98,90,,27.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.22,88,,26.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.15,33.98,
"VMA, 24HR URINE  (MAYO)",1884585,CDM,300,RC,84585,HCPCS,Outpatient,,,37.75,22.65,,32.09,85,,25.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.21,80.03,,24.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,33.98,90,,27.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.22,88,,26.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.49,33.98,
THORAZINE (chlorpromazine) 50MG INJ,293189,CDM,636,RC,J3230,HCPCS,Outpatient,,,37.85,22.71,,32.17,85,,25.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.29,80.03,,24.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.07,90,,27.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,31.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.31,88,,26.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.29,34.07,
MARCAINE/SENSORCAINE(BUPIV)0.25%MPF 30ML,292031,CDM,250,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
DONNATAL ELIX : 1OZ,292230,CDM,250,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
ZEMURON (rocuronium) DRIP 100MG /100MLNS,293507,CDM,250,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
KETALAR (ketamine) 50MG/ML INJ SYRINGE,293600,CDM,250,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
ERYTHROMYCIN OPHTH OINT 3.5G,297015,CDM,250,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
STOPS BLEEDING 20G POUCH,493360,CDM,270,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
NG TUBE FEED KANGAROO PVC 8FR 16,493808,CDM,270,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
TIP YANKAUER PEDI,493831,CDM,270,RC,,,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
Chemotherapy infusion-each additional hour,2996415,CDM,335,RC,96415,HCPCS,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.66,102,,,fee schedule,Pays at 102% of CMS APC rate,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.66,100,,,fee schedule,Pays at 100% of CMS APC rate,12.22,32.15,,9.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.58,33.11,,10.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.22,34.2,
TIGAN (trimethobenzamide) 200mg/2ml INJ,293193,CDM,636,RC,J3250,HCPCS,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,44.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.41,44.95,
PRIMAXIN (imipenem) 250 MG VIAL,296095,CDM,636,RC,J0743,HCPCS,Outpatient,,,38,22.8,,32.3,85,,25.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.41,80.03,,24.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,27.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.44,88,,26.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.93,34.2,
DRESSING STERILE 5 X 9 ABD,491008,CDM,270,RC,,,Outpatient,,,38.13,22.88,,32.41,85,,25.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.26,32.15,,9.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.52,80.03,,24.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.32,90,,27.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.26,32.15,,9.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.26,32.15,,9.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.55,88,,26.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.62,33.11,,10.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.26,34.32,
SET EXTENSION W/0.2 MICRON FILTER 16,492144,CDM,270,RC,,,Outpatient,,,38.13,22.88,,32.41,85,,25.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.26,32.15,,9.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.52,80.03,,24.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.32,90,,27.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.26,32.15,,9.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.26,32.15,,9.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.55,88,,26.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.62,33.11,,10.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.26,34.32,
FORCEP ADSON DISPOSABLE,4910091,CDM,270,RC,,,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.3,32.15,,9.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.3,32.15,,9.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.3,32.15,,9.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.66,33.11,,10.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.3,34.43,
AMITRIPTYLINE  & NORTRIPTYLINE  (MAYO),1882139,CDM,300,RC,80355,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.3,32.15,,9.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.3,32.15,,9.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.3,32.15,,9.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.66,33.11,,10.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.3,34.43,
"RAST, INSULIN ALLERGY PORK,HUMAN, BOVINE",1886013,CDM,300,RC,86003,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,34.43,
C4 COMPLEMENT SERUM  (MAYO),1886327,CDM,300,RC,86160,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,34.43,
C3 COMPLEMENT SERUM  (MAYO),1886328,CDM,300,RC,86160,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,34.43,
Blood test indicating infection with Hepatitis B,1886704,CDM,300,RC,86704,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,34.43,
Blood test indicating infection with Hepatitis B,1886705,CDM,300,RC,86704,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,34.43,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,1888312,CDM,300,RC,87205,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.95,34.43,
DURAMORPH PF (morphine) 10MG/10ML,299061,CDM,636,RC,J2270,HCPCS,Outpatient,,,38.25,22.95,,32.51,85,,26.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.61,80.03,,24.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,90,,27.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.66,88,,26.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,34.43,
BANDAGE GAUZE 6  STRETCH STERILE,49137,CDM,270,RC,,,Outpatient,,,38.44,23.06,,32.67,85,,26.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.36,32.15,,9.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.76,80.03,,24.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.6,90,,27.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.36,32.15,,9.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.36,32.15,,9.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.83,88,,27.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.73,33.11,,10.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.36,34.6,
AMNIO HOOK,490038,CDM,270,RC,,,Outpatient,,,38.44,23.06,,32.67,85,,26.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.36,32.15,,9.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.76,80.03,,24.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.6,90,,27.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.36,32.15,,9.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.36,32.15,,9.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.83,88,,27.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.73,33.11,,10.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.36,34.6,
FILTER SET,20001,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CASTING 2  WHITE DELTA-LITE,493135,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  GREEN DELTA-LITE,493182,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  BLACK DELTA-LITE,493186,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  DK BLUE DELTA-LITE,493188,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  LT BLUE DELTA-LITE,493190,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  NEON PINK DELTA-LITE,493192,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  PURPLE DELTA-LITE,493194,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  RED DELTA-LITE,493196,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
TAPE CAST 2  NEON YELLOW DELTA-LITE,493198,CDM,270,RC,,,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.38,32.15,,9.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,33.11,,10.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.38,34.65,
Blood test to measure the level of lipoproteins in the blood,1883718,CDM,300,RC,83718,HCPCS,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.3,34.65,
Blood test to monitor for cytomegalovirus,1887816,CDM,300,RC,86644,HCPCS,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,34.65,
CRYSTAL ANALYSIS,1889060,CDM,300,RC,89060,HCPCS,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.47,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.47,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.99,34.65,
.RH,2086901,CDM,300,RC,86901,HCPCS,Outpatient,,,38.5,23.1,,32.73,85,,26.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.81,80.03,,24.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,34.65,90,,27.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.88,88,,27.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.51,34.65,
NITROSTAT IV INFUSION KIT,293127,CDM,250,RC,,,Outpatient,,,38.63,23.18,,32.84,85,,26.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.92,80.03,,24.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,90,,27.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.99,88,,27.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.79,33.11,,10.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.42,34.77,
NIZORAL (KETOCONAZOLE) SHAMPOO 4OZ,297041,CDM,250,RC,,,Outpatient,,,38.63,23.18,,32.84,85,,26.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.92,80.03,,24.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,90,,27.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.99,88,,27.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.79,33.11,,10.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.42,34.77,
GRANULEX SPRAY 4 OZ,298010,CDM,250,RC,,,Outpatient,,,38.63,23.18,,32.84,85,,26.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.92,80.03,,24.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,90,,27.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.99,88,,27.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.79,33.11,,10.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.42,34.77,
GELFOAM POWDER 1GM,298049,CDM,250,RC,,,Outpatient,,,38.63,23.18,,32.84,85,,26.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.92,80.03,,24.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,90,,27.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.99,88,,27.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.79,33.11,,10.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.42,34.77,
NS IRG 1000ML,296540,CDM,258,RC,,,Outpatient,,,38.63,23.18,,32.84,85,,26.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.92,80.03,,24.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,90,,27.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.42,32.15,,9.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.99,88,,27.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.79,33.11,,10.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.42,34.77,
ERYTHROMYCIN 500MG / NS100ML,293080,CDM,636,RC,J1364,HCPCS,Outpatient,,,38.63,23.18,,32.84,85,,26.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.92,80.03,,24.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,85.31,102,,,fee schedule,Pays at 102% of CMS APC rate,34.77,90,,27.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.31,100,,,fee schedule,Pays at 100% of CMS APC rate,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.99,88,,27.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,86.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.92,83.64,
NEBCIN  (tobramycin) 60MG /SW 15ML PB,293122,CDM,636,RC,J3260,HCPCS,Outpatient,,,38.63,23.18,,32.84,85,,26.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.92,80.03,,24.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,90,,27.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.99,88,,27.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.65,34.77,
CATH ULTRAMER 10FR URETHRAL RED RUBBER,49606,CDM,270,RC,,,Outpatient,,,38.75,23.25,,32.94,85,,26.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.01,80.03,,24.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.88,90,,27.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.1,88,,27.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.83,33.11,,10.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.46,34.88,
CATH ULTRAMER 12FR URETHRAL RED RUBBER,49612,CDM,270,RC,,,Outpatient,,,38.75,23.25,,32.94,85,,26.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.01,80.03,,24.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.88,90,,27.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.1,88,,27.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.83,33.11,,10.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.46,34.88,
CATH ULTRAMER 20FR URETHRAL RED RUBBER,49636,CDM,270,RC,,,Outpatient,,,38.75,23.25,,32.94,85,,26.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.01,80.03,,24.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.88,90,,27.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.1,88,,27.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.83,33.11,,10.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.46,34.88,
SHIELD EYE FOX,493011,CDM,270,RC,,,Outpatient,,,38.75,23.25,,32.94,85,,26.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.01,80.03,,24.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.88,90,,27.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.1,88,,27.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.83,33.11,,10.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.46,34.88,
"METANEPHRINES FRACT RANDOM, U  (MAYO)",1883837,CDM,300,RC,83835,HCPCS,Outpatient,,,38.75,23.25,,32.94,85,,26.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.01,80.03,,24.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.88,90,,27.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.1,88,,27.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.3,34.88,
DIGITAL BREAST TOMOSYNTHESIS; UNILATERAL,2277061,CDM,614,RC,77061,HCPCS,Outpatient,,,38.75,23.25,,32.94,85,,26.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.01,80.03,,24.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.88,90,,27.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.46,32.15,,9.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.1,88,,27.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.83,33.11,,10.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.46,34.88,
"MACROPROLACTIN, S  (MAYO)",1882440,CDM,300,RC,84146,HCPCS,Outpatient,,,38.76,23.26,,32.95,85,,26.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.02,80.03,,24.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,34.88,90,,27.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.11,88,,27.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.37,34.88,
MAGNESIUM,1883735,CDM,300,RC,83735,HCPCS,Outpatient,,,38.95,23.37,,33.11,85,,26.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.17,80.03,,24.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.06,90,,28.05,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.28,88,,27.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.42,35.06,
ENLON-PLUS 50MG/5ML,293101,CDM,250,RC,,,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.91,33.11,,10.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.54,35.1,
PEPCID (famotidine) : 20MG VIAL,293324,CDM,250,RC,,,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.91,33.11,,10.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.54,35.1,
PEPCID (famotidine)20MG/50ML NS PB,293340,CDM,250,RC,,,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.91,33.11,,10.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.54,35.1,
KETALAR (ketamine) 500MG/10ML INJ,293470,CDM,250,RC,,,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.91,33.11,,10.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.54,35.1,
MYCOSTATIN (nystatin ) OINT 15GM,297032,CDM,250,RC,,,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.91,33.11,,10.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.54,35.1,
PROVIGIL (MODAFINIL) 200 MG TAB,299041,CDM,250,RC,,,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.91,33.11,,10.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.54,35.1,
PENTOTHAL (thiopental)500MG DOSE,299069,CDM,250,RC,,,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.54,32.15,,10.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.91,33.11,,10.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.54,35.1,
Blood test to determine if antibodies exist for measles,1882685,CDM,300,RC,86765,HCPCS,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,35.1,
Blood test to determine if antibodies exist for measles,1886766,CDM,300,RC,86765,HCPCS,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,35.1,
PLATELET CROSSMATCH,1887811,CDM,300,RC,86022,HCPCS,Outpatient,,,39,23.4,,33.15,85,,26.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.21,80.03,,24.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.1,90,,28.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.32,88,,27.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.09,35.1,
CEFOTAN (CEFOTETAN) : 1GM VIAL,293350,CDM,250,RC,S0074,HCPCS,Outpatient,,,39.14,23.48,,33.27,85,,26.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.32,80.03,,25.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.23,90,,28.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.44,88,,27.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.96,33.11,,10.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.58,35.23,
LANOXIN (digoxin) 0.05MG/ML ELIXIR :60ML,294022,CDM,250,RC,,,Outpatient,,,39.14,23.48,,33.27,85,,26.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.32,80.03,,25.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.23,90,,28.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.44,88,,27.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.96,33.11,,10.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.58,35.23,
TRAVASE OINTMENT,296062,CDM,250,RC,,,Outpatient,,,39.14,23.48,,33.27,85,,26.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.32,80.03,,25.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.23,90,,28.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.44,88,,27.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.96,33.11,,10.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.58,35.23,
LOTRISONE CRM (BETAMETHASONE/CLOTRIM)15G,297077,CDM,250,RC,,,Outpatient,,,39.14,23.48,,33.27,85,,26.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.32,80.03,,25.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.23,90,,28.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.44,88,,27.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.96,33.11,,10.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.58,35.23,
BETOPTIC S  0.25% OPTH SOLN 5ML,297522,CDM,250,RC,,,Outpatient,,,39.14,23.48,,33.27,85,,26.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.32,80.03,,25.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.23,90,,28.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.58,32.15,,10.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.44,88,,27.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.96,33.11,,10.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.58,35.23,
SPLINT AQUAPLAST 3  X 3  NASAL,49726,CDM,270,RC,,,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.62,32.15,,10.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.62,32.15,,10.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.62,32.15,,10.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13,33.11,,10.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.62,35.33,
KIT APPLICATOR PREP STEP-ONE MERLIN,491509,CDM,270,RC,,,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.62,32.15,,10.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.62,32.15,,10.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.62,32.15,,10.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13,33.11,,10.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.62,35.33,
"COPPER, SERUM  (MAYO)",1882525,CDM,300,RC,82525,HCPCS,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.61,35.33,
"BARTONELLA HENSELAE AB, IGG  (MAYO)",1886607,CDM,300,RC,86611,HCPCS,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.8,35.33,
"BARTONELLA HENSELAE AB, IGM  (MAYO)",1886608,CDM,300,RC,86611,HCPCS,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.8,35.33,
"BARTONELLA QUINTANA AB, IGG  (MAYO)",1886611,CDM,300,RC,86611,HCPCS,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.8,35.33,
"BARTONELLA QUINTANA AB, IGM  (MAYO)",1886612,CDM,300,RC,86611,HCPCS,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.8,35.33,
"KOH PREP, FUNGUS  (MAYO)",1887214,CDM,300,RC,87220,HCPCS,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.36,35.33,
"SMEAR FOR WBC, STOOL",1889190,CDM,300,RC,89055,HCPCS,Outpatient,,,39.25,23.55,,33.36,85,,26.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.41,80.03,,25.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.33,90,,28.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.54,88,,27.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.95,35.33,
D5W 500ML,296153,CDM,258,RC,J7060,HCPCS,Outpatient,,,39.3,23.58,,33.41,85,,26.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.45,80.03,,25.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.37,90,,28.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.58,88,,27.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.63,35.37,
ALCOHOL ETHYL (98%) : 5ML AMP,293823,CDM,250,RC,,,Outpatient,,,39.35,23.61,,33.45,85,,26.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.65,32.15,,10.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.49,80.03,,25.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.42,90,,28.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.65,32.15,,10.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.65,32.15,,10.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.63,88,,27.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.03,33.11,,10.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.65,35.42,
LANTUS  (glargine) 100 UNIT/ML INSULIN,293461,CDM,250,RC,,,Outpatient,,,39.5,23.7,,33.58,85,,26.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.7,32.15,,10.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.61,80.03,,25.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.55,90,,28.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.7,32.15,,10.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.7,32.15,,10.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.76,88,,27.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.08,33.11,,10.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.7,35.55,
ALCOHOL-ETHANOL BLOOD,1882055,CDM,300,RC,82077,HCPCS,Outpatient,,,39.57,23.74,,33.63,85,,26.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.67,80.03,,25.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.61,90,,28.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.82,88,,27.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.82,35.61,
DURAGESIC (fentanyl) 50mcg PATCH,292062,CDM,250,RC,,,Outpatient,,,39.66,23.8,,33.71,85,,26.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.75,32.15,,10.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.74,80.03,,25.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.69,90,,28.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.75,32.15,,10.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.75,32.15,,10.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.9,88,,27.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.13,33.11,,10.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.75,35.69,
"DRESSING, VAC DRAPE 12 X10",43834,CDM,270,RC,,,Outpatient,,,39.75,23.85,,33.79,85,,27.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.78,32.15,,10.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.81,80.03,,25.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.78,90,,28.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.78,32.15,,10.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.78,32.15,,10.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.98,88,,27.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.16,33.11,,10.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.78,35.78,
VALVE BRONCHOSCOPE SUCTION SINGLE USE,492190,CDM,270,RC,,,Outpatient,,,39.75,23.85,,33.79,85,,27.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.78,32.15,,10.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.81,80.03,,25.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.78,90,,28.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.78,32.15,,10.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.78,32.15,,10.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.98,88,,27.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.16,33.11,,10.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.78,35.78,
PINWORM ANALYSIS,1887212,CDM,300,RC,87172,HCPCS,Outpatient,,,39.75,23.85,,33.79,85,,27.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.81,80.03,,25.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,35.78,90,,28.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.98,88,,27.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.36,35.78,
NS (normal saline) :500ML,296290,CDM,258,RC,J7040,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.29,36,
ISOLETTE,30065,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
.TRACH MASK,30210,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
.IPPB CIRCUIT,30365,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
CRADLE,49095,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
DRESSING ADAPTIC 3X3,49996,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
CUFF NEONATAL PRESSURE #2 2/T,493108,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
SURFIT ONE PIECE DRAIN POUCH  (ACTIVE LI,493230,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
DRESSING EXUDERM 6X6 ODORSHIELD,498009,CDM,270,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
CLINICAL NUTRICIAN,12007,CDM,300,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
Quantitative measure of glucose build up in the blood over time,120007,CDM,300,RC,82947,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,36,
zCK ISOENZYME SERUM  (MAYO),1882551,CDM,300,RC,82552,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.84,36,
"BODY FLUID, PROTEIN  (MAYO)",1882961,CDM,300,RC,84157,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.61,36,
Blood test indicating infection with Hepatitis A,1886296,CDM,300,RC,86708,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.05,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.58,36,
Test to determine levels of immunoglobulins in the blood,1886423,CDM,300,RC,82784,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.69,36,
WOUND MANAGEMENT,392,CDM,420,RC,97139,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
P/T SETUP TRAPEZE,31110,CDM,420,RC,97122,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
One time use unattended,311005,CDM,420,RC,97014,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",311007,CDM,420,RC,97016,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.44,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
DO NOT USE,311009,CDM,420,RC,97039,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
Manipulation of 1 or more regions of the body,311012,CDM,420,RC,97140,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,311013,CDM,420,RC,97033,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",311015,CDM,420,RC,97035,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311025,CDM,420,RC,97110,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
Repeated application to one or more parts of the body,311029,CDM,420,RC,97032,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
WOUND MANAGEMENT,311205,CDM,420,RC,97139,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
OT EVALUATION,313001,CDM,430,RC,97750,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",313011,CDM,430,RC,97110,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
ADL TRAINING,313030,CDM,430,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
Manipulation of 1 or more regions of the body,590011,CDM,430,RC,97140,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
SPEECH GROUP ACTIVITY,312006,CDM,440,RC,92508,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.02,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.02,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
GENTAMICIN 60MG VIAL,293358,CDM,636,RC,J1580,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,36,
PENICILLIN: 2.5 MU/ NS 50ML  PB,293848,CDM,636,RC,J2510,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
ROCEPHIN (ceftriaxone) 1G /NS 100ML IVPB,300165,CDM,636,RC,J0696,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.47,36,
GENTAMICIN 120MG/100ML NS IVPB,300173,CDM,636,RC,J1580,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,36,
ANCEF (cefazolin)  1GM/ NS 50ML PB,300227,CDM,636,RC,J0690,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,36,
LIDOCAINE 1.5% WITH EPI 1:200 30ML VIAL,301302,CDM,636,RC,J2001,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.03,36,
ANCEF (cefazolin)  3 GM/ NS 100ML PB,302366,CDM,636,RC,J0690,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,36,
FLU VACCINE ADMINISTRATION,75005,CDM,771,RC,G0008,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
CARDIAC REHAB W/OUT EKG MAINTENANCE,399,CDM,943,RC,,,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.86,32.15,,10.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.24,33.11,,10.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.86,36,
ALBUTEROL MDV 0.5%(2.5MG/0.5ML)BOTT**20M,292100,CDM,250,RC,,,Outpatient,,,40.05,24.03,,34.04,85,,27.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.88,32.15,,10.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.05,80.03,,25.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.05,90,,28.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.88,32.15,,10.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.88,32.15,,10.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.24,88,,28.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.26,33.11,,10.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.88,36.05,
LEVAQUIN (levofloxacin) 750MG TAB,29886,CDM,250,RC,,,Outpatient,,,40.15,24.09,,34.13,85,,27.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.13,80.03,,25.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.14,90,,28.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.33,88,,28.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.29,33.11,,10.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.91,36.14,
TIMOPTIC (timolol) 0.5% OPTH 10ML,297733,CDM,250,RC,,,Outpatient,,,40.15,24.09,,34.13,85,,27.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.13,80.03,,25.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.14,90,,28.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.33,88,,28.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.29,33.11,,10.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.91,36.14,
VIGAMOX (moxifloxacin) OPHTH SOL: U/D,303952,CDM,250,RC,,,Outpatient,,,40.16,24.1,,34.14,85,,27.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.14,80.03,,25.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.14,90,,28.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.91,32.15,,10.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.34,88,,28.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.3,33.11,,10.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.91,36.14,
AMPICILLIN : 2GM VIAL,293395,CDM,636,RC,J0290,HCPCS,Outpatient,,,40.2,24.12,,34.17,85,,27.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.17,80.03,,25.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.18,90,,28.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.38,88,,28.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,36.18,
SET EXTENSION WITH  T,492155,CDM,270,RC,,,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.94,32.15,,10.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.94,32.15,,10.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,12.94,32.15,,10.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.33,33.11,,10.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.94,36.23,
Quantitative measure of glucose build up in the blood over time,4001,CDM,300,RC,82947,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,36.23,
Quantitative measure of glucose build up in the blood over time,5001,CDM,300,RC,82947,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,36.23,
Quantitative measure of glucose build up in the blood over time,6002,CDM,300,RC,82947,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,36.23,
Test to measure creatinine in the urine,1882570,CDM,300,RC,82570,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,36.23,
HAPTOGLOBIN  (MAYO),1883011,CDM,300,RC,83010,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.69,36.23,
LITHIUM (MAYO),1883725,CDM,300,RC,80178,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.32,36.23,
URINE PROTEIN 24HR,1884180,CDM,300,RC,84156,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.61,36.23,
SGOT/AST,1884455,CDM,300,RC,84450,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,36.23,
HISTOPLASMA AB SERUM  (MAYO),1886171,CDM,300,RC,86698,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.71,36.23,
ASPERGILLAS AB  (MAYO),1886330,CDM,300,RC,86606,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.93,36.23,
ACID FAST SMEAR (MAYO),1887204,CDM,300,RC,87206,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,36.23,
A lab test to screen for evidence of vaginal infection,1887211,CDM,300,RC,87210,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.36,36.23,
"CHROMO ANALYSIS; ADD'L CELLS COUNTED, EA",2188283,CDM,300,RC,88285,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.44,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.44,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.89,36.23,
HAND HELD NEBULIZER TX,30010,CDM,410,RC,94640,HCPCS,Outpatient,,,40.25,24.15,,34.21,85,,27.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.94,32.15,,10.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.21,80.03,,25.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,36.23,90,,28.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.94,32.15,,10.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,12.94,32.15,,10.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.42,88,,28.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.33,33.11,,10.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,12.94,36.23,
D5 1/2NS W/KCL 10 MEQ 500 ML,296211,CDM,258,RC,J7042,HCPCS,Outpatient,,,40.3,24.18,,34.26,85,,27.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.25,80.03,,25.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.27,90,,29.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.46,88,,28.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.17,36.27,
NS (normal saline) :1000ML,296296,CDM,250,RC,J7030,HCPCS,Outpatient,,,40.35,24.21,,34.3,85,,27.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.29,80.03,,25.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.32,90,,29.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.51,88,,28.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.58,36.32,
MICRONEFRIN (RACEMIC EPINEPHRINE) SOLN,292037,CDM,250,RC,,,Outpatient,,,40.43,24.26,,34.37,85,,27.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13,32.15,,10.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.36,80.03,,25.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.39,90,,29.11,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13,32.15,,10.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13,32.15,,10.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.58,88,,28.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.39,33.11,,10.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13,36.39,
COLY-MYCIN S OTIC 5ML,297802,CDM,250,RC,,,Outpatient,,,40.43,24.26,,34.37,85,,27.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13,32.15,,10.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.36,80.03,,25.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.39,90,,29.11,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13,32.15,,10.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13,32.15,,10.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.58,88,,28.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.39,33.11,,10.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13,36.39,
COBAN 3  STERILE SELF-ADHERENT WRAP,49110,CDM,270,RC,,,Outpatient,,,40.5,24.3,,34.43,85,,27.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.02,32.15,,10.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.41,80.03,,25.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.45,90,,29.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.02,32.15,,10.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.02,32.15,,10.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.64,88,,28.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.41,33.11,,10.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.02,36.45,
Blood test to determine cause of inappropriate blood clot formation,1886251,CDM,300,RC,86147,HCPCS,Outpatient,,,40.5,24.3,,34.43,85,,27.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.41,80.03,,25.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.45,90,,29.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.64,88,,28.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.99,36.45,
Blood test to monitor for cytomegalovirus,1887516,CDM,300,RC,86644,HCPCS,Outpatient,,,40.5,24.3,,34.43,85,,27.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.41,80.03,,25.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.45,90,,29.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.64,88,,28.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,36.45,
SELECTED CELL PANEL,1887815,CDM,300,RC,86885,HCPCS,Outpatient,,,40.5,24.3,,34.43,85,,27.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.41,80.03,,25.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,36.45,90,,29.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,7.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.64,88,,28.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.19,36.45,
BANDAGE ACE 6,49132,CDM,270,RC,,,Outpatient,,,40.63,24.38,,34.54,85,,27.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.06,32.15,,10.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.52,80.03,,26.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.57,90,,29.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.06,32.15,,10.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.06,32.15,,10.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.75,88,,28.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.45,33.11,,10.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.06,36.57,
DRESSING VAC WHITE FOAM SMALL,49681,CDM,270,RC,,,Outpatient,,,40.75,24.45,,34.64,85,,27.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.61,80.03,,26.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.68,90,,29.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.86,88,,28.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.49,33.11,,10.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.1,36.68,
DRAPE SPLIT 77  X 108,496160,CDM,270,RC,,,Outpatient,,,40.75,24.45,,34.64,85,,27.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.61,80.03,,26.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.68,90,,29.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.86,88,,28.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.49,33.11,,10.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.1,36.68,
STYLET 10FR INTUBATING,4985864,CDM,270,RC,,,Outpatient,,,40.75,24.45,,34.64,85,,27.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.61,80.03,,26.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.68,90,,29.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.1,32.15,,10.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.86,88,,28.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.49,33.11,,10.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.1,36.68,
EOSINOPHIL ABSOLUTE,1885049,CDM,300,RC,85048,HCPCS,Outpatient,,,40.75,24.45,,34.64,85,,27.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.61,80.03,,26.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.68,90,,29.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.86,88,,28.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.2,36.68,
Test for strep A,1887060,CDM,300,RC,87880,HCPCS,Outpatient,,,40.8,24.48,,34.68,85,,27.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.65,80.03,,26.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,36.72,90,,29.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.9,88,,28.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,36.72,
BANDAGE ACE 2,49114,CDM,270,RC,,,Outpatient,,,40.94,24.56,,34.8,85,,27.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.16,32.15,,10.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.76,80.03,,26.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.85,90,,29.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.16,32.15,,10.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.16,32.15,,10.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.03,88,,28.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.56,33.11,,10.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.16,36.85,
UNIPEN (nafcillin) : 2GM VIAL,293386,CDM,250,RC,,,Outpatient,,,40.95,24.57,,34.81,85,,27.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.17,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.77,80.03,,26.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.86,90,,29.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.17,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.17,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.04,88,,28.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.56,33.11,,10.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.17,36.86,
ERY-PED (ery ethylsuc) 200MG/5ML SUSP100,295189,CDM,250,RC,,,Outpatient,,,40.95,24.57,,34.81,85,,27.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.17,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.77,80.03,,26.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.86,90,,29.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.17,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.17,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.04,88,,28.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.56,33.11,,10.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.17,36.86,
NEBCIN (tobramycin) 80MG /SW 20ML PB,293123,CDM,636,RC,J3260,HCPCS,Outpatient,,,40.95,24.57,,34.81,85,,27.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.77,80.03,,26.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.86,90,,29.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.04,88,,28.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.65,36.86,
IV THERAPY NEW DRUG CONCURRENTLY,96368,CDM,260,RC,96368,HCPCS,Outpatient,,,41,24.6,,34.85,85,,27.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.81,80.03,,26.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.9,90,,29.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.08,88,,28.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.58,33.11,,10.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.18,36.9,
OXYGEN TRANSPORT,3030,CDM,270,RC,,,Outpatient,,,41,24.6,,34.85,85,,27.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.81,80.03,,26.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.9,90,,29.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.08,88,,28.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.58,33.11,,10.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.18,36.9,
DRAPE SLUSH XL 44X66 STERILE,496161,CDM,270,RC,,,Outpatient,,,41,24.6,,34.85,85,,27.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.81,80.03,,26.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.9,90,,29.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.08,88,,28.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.58,33.11,,10.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.18,36.9,
FORCEP SPLINTER FINE POINT DISPOSABLE,4910088,CDM,270,RC,,,Outpatient,,,41,24.6,,34.85,85,,27.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.81,80.03,,26.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.9,90,,29.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.08,88,,28.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.58,33.11,,10.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.18,36.9,
METHOTREXATE  (MAYO),1880301,CDM,300,RC,80299,HCPCS,Outpatient,,,41.25,24.75,,35.06,85,,28.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.01,80.03,,26.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.13,90,,29.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.3,88,,29.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,37.13,
"PYRUVIC ACID, BLOOD  (MAYO)",1884210,CDM,300,RC,84210,HCPCS,Outpatient,,,41.25,24.75,,35.06,85,,28.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.01,80.03,,26.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.13,90,,29.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.3,88,,29.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.65,37.13,
HEPATITIS B SURFACE AG (HBsAG)  (MAYO),1886287,CDM,300,RC,87340,HCPCS,Outpatient,,,41.25,24.75,,35.06,85,,28.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.01,80.03,,26.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.53,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.13,90,,29.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.53,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.3,88,,29.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.99,37.13,
NITROL (nitroglycerin) OINT 60 GM TUBE,297040,CDM,250,RC,,,Outpatient,,,41.35,24.81,,35.15,85,,28.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.29,32.15,,10.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.09,80.03,,26.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.22,90,,29.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.29,32.15,,10.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.29,32.15,,10.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.39,88,,29.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.69,33.11,,10.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.29,37.22,
NALDECON PED DROPS: 30ML,294054,CDM,250,RC,,,Outpatient,,,41.46,24.88,,35.24,85,,28.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.18,80.03,,26.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.31,90,,29.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.48,88,,29.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.73,33.11,,10.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.33,37.31,
SOD CHLOR 5%: 500ML,296320,CDM,258,RC,J7131,HCPCS,Outpatient,,,41.46,24.88,,35.24,85,,28.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.18,80.03,,26.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.31,90,,29.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.48,88,,29.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.73,33.11,,10.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.33,37.31,
NS IRG 2000ML,296546,CDM,258,RC,,,Outpatient,,,41.46,24.88,,35.24,85,,28.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.18,80.03,,26.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.31,90,,29.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.48,88,,29.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.73,33.11,,10.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.33,37.31,
STER WATER IRG 2000ML,296564,CDM,258,RC,,,Outpatient,,,41.46,24.88,,35.24,85,,28.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.18,80.03,,26.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.31,90,,29.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.33,32.15,,10.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.48,88,,29.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.73,33.11,,10.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.33,37.31,
UNASYN (amp/sulbactam): 3GM VIAL,293309,CDM,636,RC,J0295,HCPCS,Outpatient,,,41.46,24.88,,35.24,85,,28.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.18,80.03,,26.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.31,90,,29.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.48,88,,29.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.05,37.31,
BEDBOARD WHILE IN USE,49090,CDM,270,RC,,,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
ASPIRATOR MECONIUM,49391,CDM,270,RC,,,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
SPLINT BASEBALL FINGER MEDIUM,491313,CDM,270,RC,,,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
SET EXTENSION T-PORT 6,492157,CDM,270,RC,,,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
TUBE LEVIN 12FR,493813,CDM,270,RC,,,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
WORD CATHETER BARTHOLIN GLAND BALLOON,4955442,CDM,270,RC,C1889,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
DRESSING OPTIFOAM 3  X 3  BASIC,498028,CDM,272,RC,,,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
DRESSING QUICK 6.125  X 8,498033,CDM,272,RC,,,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
Blood test to diagnose rheumatoid arthritis,1883510,CDM,300,RC,86200,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,37.35,
"MYOGLOBIN, URINE  (MAYO)",1883872,CDM,300,RC,83874,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.17,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.17,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.24,37.35,
"STONE QT ANALYSIS, CHEMICAL",1884107,CDM,300,RC,82360,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,37.35,
"SEROTONIN, 5-HIAA  24HR URINE  (MAYO)",1884260,CDM,300,RC,83497,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.21,37.35,
"Blood test, clotting time",1885611,CDM,300,RC,85610,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.37,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.37,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.94,37.35,
Coagulation assessment blood test,1885731,CDM,300,RC,85730,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.54,37.35,
COXSACKIE A  (MAYO),1886172,CDM,300,RC,86658,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.38,37.35,
COXSACKIE B  (MAYO),1886173,CDM,300,RC,86658,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.38,37.35,
VARICELLA ZOSTER IGG  (MAYO),1886224,CDM,300,RC,86787,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,37.35,
SM ANTIBODIES (MAYO),1886235,CDM,300,RC,86235,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,37.35,
"MUMPS AB, IGG  (MAYO)",1886265,CDM,300,RC,86735,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.31,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.31,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.41,37.35,
Blood test indicating infection with Hepatitis A,1886299,CDM,300,RC,86708,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.05,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.58,37.35,
VARICELLA ZOSTER IGM  (MAYO),1886786,CDM,300,RC,86787,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,37.35,
MEDICAL NUTRITION THERPY / INDV / 15 MIN,97802,CDM,942,RC,97802,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.46,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.46,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
DIABETES SELF-MGMT TRAIN / INDV / 30 MIN,98960,CDM,942,RC,98960,HCPCS,Outpatient,,,41.5,24.9,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.21,80.03,,26.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.35,90,,29.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.34,32.15,,10.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.52,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.34,37.35,
LOVENOX  VIAL  (ENOXAPARIN) 30MG/0.3ML,293426,CDM,250,RC,,,Outpatient,,,41.51,24.91,,35.28,85,,28.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.35,32.15,,10.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.22,80.03,,26.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.36,90,,29.89,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.35,32.15,,10.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.35,32.15,,10.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.53,88,,29.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.74,33.11,,10.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.35,37.36,
TRAY SUTURE REMOVAL,493004,CDM,270,RC,,,Outpatient,,,41.56,24.94,,35.33,85,,28.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.36,32.15,,10.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.26,80.03,,26.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.4,90,,29.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.36,32.15,,10.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.36,32.15,,10.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.57,88,,29.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.76,33.11,,11.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.36,37.4,
Culture of the urine to determine bacterial infection,1887086,CDM,300,RC,87088,HCPCS,Outpatient,,,41.62,24.97,,35.38,85,,28.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.31,80.03,,26.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.46,90,,29.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.63,88,,29.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.18,37.46,
BARRIER PROTECTIVE SENSI-CARE,491511,CDM,270,RC,,,Outpatient,,,41.75,25.05,,35.49,85,,28.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.41,80.03,,26.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.58,90,,30.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.74,88,,29.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.82,33.11,,11.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.42,37.58,
SET EXTENSION CARESITE 6,492148,CDM,270,RC,,,Outpatient,,,41.75,25.05,,35.49,85,,28.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.41,80.03,,26.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.58,90,,30.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.74,88,,29.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.82,33.11,,11.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.42,37.58,
CSF BANDS  (MAYO),1882053,CDM,300,RC,83916,HCPCS,Outpatient,,,41.75,25.05,,35.49,85,,28.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.41,80.03,,26.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.58,90,,30.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.74,88,,29.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.28,37.58,
SERUM BANDS  (MAYO),1882054,CDM,300,RC,83916,HCPCS,Outpatient,,,41.75,25.05,,35.49,85,,28.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.41,80.03,,26.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.58,90,,30.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.74,88,,29.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.28,37.58,
.THYROID AUTOANTIBODIES PROFILE  (MAYO),1886375,CDM,300,RC,,,Outpatient,,,41.75,25.05,,35.49,85,,28.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.41,80.03,,26.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.58,90,,30.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.42,32.15,,10.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.74,88,,29.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.82,33.11,,11.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.42,37.58,
.THYROID MICROSOMAL - OBSOLETE,1886800,CDM,300,RC,86376,HCPCS,Outpatient,,,41.75,25.05,,35.49,85,,28.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.41,80.03,,26.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.58,90,,30.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.74,88,,29.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.3,37.58,
PAP SMEAR ROUTINE,2188150,CDM,311,RC,88164,HCPCS,Outpatient,,,41.75,25.05,,35.49,85,,28.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.41,80.03,,26.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.58,90,,30.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.74,88,,29.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.28,37.58,
LIDEX CREAM (fluocinonide) 0.05% 15GM,297034,CDM,250,RC,,,Outpatient,,,41.98,25.19,,35.68,85,,28.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.6,80.03,,26.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.78,90,,30.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.94,88,,29.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.9,33.11,,11.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.78,
FML LIQUIFILM 5ML,297514,CDM,250,RC,,,Outpatient,,,41.98,25.19,,35.68,85,,28.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.6,80.03,,26.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.78,90,,30.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.94,88,,29.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.9,33.11,,11.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.78,
ATIVAN (lorazepam): 2MG INJ,293034,CDM,636,RC,J2060,HCPCS,Outpatient,,,41.98,25.19,,35.68,85,,28.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.6,80.03,,26.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.78,90,,30.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.94,88,,29.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.9,33.11,,11.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.78,
ATIVAN (lorazepam): 4MG/ML 1ML INJ**,293595,CDM,636,RC,J2060,HCPCS,Outpatient,,,41.98,25.19,,35.68,85,,28.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.6,80.03,,26.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.78,90,,30.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.94,88,,29.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.9,33.11,,11.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.78,
HUMALOG 75/25 MIX PEN**NF,293452,CDM,250,RC,J1815,HCPCS,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.31,37.8,
STER WATER  IRG 1000ML,296565,CDM,258,RC,,,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.91,33.11,,11.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.8,
SPECULA VAGINAL MEDIUM DISPOSABLE,49057,CDM,270,RC,,,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.91,33.11,,11.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.8,
LINERS BUNNY BOOT,314020,CDM,270,RC,,,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.91,33.11,,11.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.8,
CLEANER SAF-CLENS AF,491508,CDM,270,RC,,,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.91,33.11,,11.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.8,
CLOSURE TAIL SURE-FIT,493204,CDM,270,RC,,,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.91,33.11,,11.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.8,
"OSMOLALITY, BODY FLUID  (MAYO)",1883932,CDM,300,RC,83930,HCPCS,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.32,37.8,
Manipulation of 1 or more regions of the body,324,CDM,420,RC,97140,HCPCS,Outpatient,,,42,25.2,,35.7,85,,28.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.61,80.03,,26.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,37.8,90,,30.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,13.5,32.15,,10.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.96,88,,29.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.91,33.11,,11.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.5,37.8,
ACCU-CHEK   CHEMSTRIPS INFORM II (BX),292081,CDM,270,RC,,,Outpatient,,,42.03,25.22,,35.73,85,,28.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.51,32.15,,10.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.64,80.03,,26.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.83,90,,30.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.51,32.15,,10.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.51,32.15,,10.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.99,88,,29.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.92,33.11,,11.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.51,37.83,
TAGAMET (CIMETIDINE) : 300MG PB,293180,CDM,250,RC,,,Outpatient,,,42.25,25.35,,35.91,85,,28.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.81,80.03,,27.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.03,90,,30.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.18,88,,29.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.99,33.11,,11.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.58,38.03,
CUFF NEONATAL PRESSURE #3 2/T,493107,CDM,270,RC,,,Outpatient,,,42.25,25.35,,35.91,85,,28.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.81,80.03,,27.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.03,90,,30.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.18,88,,29.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.99,33.11,,11.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.58,38.03,
CUFF NEONATAL PRESSURE #4 2/T,493109,CDM,270,RC,,,Outpatient,,,42.25,25.35,,35.91,85,,28.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,33.81,80.03,,27.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.03,90,,30.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.58,32.15,,10.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.18,88,,29.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.99,33.11,,11.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.58,38.03,
"BETA 2 GLYCOPROTEIN AB,IGA  (MAYO)",1882232,CDM,300,RC,86146,HCPCS,Outpatient,,,42.25,25.35,,35.91,85,,28.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.81,80.03,,27.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.03,90,,30.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.18,88,,29.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.99,38.03,
"MAGNESIUM, 24HR  (MAYO)",1882438,CDM,300,RC,83735,HCPCS,Outpatient,,,42.25,25.35,,35.91,85,,28.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.81,80.03,,27.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.03,90,,30.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.18,88,,29.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.42,38.03,
"MAGNESIUM, URINE RANDOM  (MAYO)",1882439,CDM,300,RC,83735,HCPCS,Outpatient,,,42.25,25.35,,35.91,85,,28.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.81,80.03,,27.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.03,90,,30.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.18,88,,29.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.42,38.03,
DIRECT COOMBS,1887805,CDM,300,RC,86880,HCPCS,Outpatient,,,42.25,25.35,,35.91,85,,28.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.81,80.03,,27.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,38.03,90,,30.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.18,88,,29.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,38.03,
"Blood test, thyroid stimulating hormone (TSH)",1884444,CDM,300,RC,84443,HCPCS,Outpatient,,,42.44,25.46,,36.07,85,,28.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.96,80.03,,27.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.2,90,,30.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.35,88,,29.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.12,38.2,
LOPROX (CICLOPIROX) 0.77% (1%) CRM 30GM,297083,CDM,250,RC,,,Outpatient,,,42.49,25.49,,36.12,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34,80.03,,27.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.24,90,,30.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.39,88,,29.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.07,33.11,,11.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.66,38.24,
BETOPTIC 0.5% OPTH 5ML,297756,CDM,250,RC,,,Outpatient,,,42.49,25.49,,36.12,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34,80.03,,27.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.24,90,,30.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.39,88,,29.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.07,33.11,,11.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.66,38.24,
ANCEF (cefazolin)  2GM/ 20ML SW  PB,293270,CDM,636,RC,J0690,HCPCS,Outpatient,,,42.49,25.49,,36.12,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34,80.03,,27.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.24,90,,30.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.39,88,,29.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,38.24,
"HEPARIN 25,000 UNITS/ 500ML PREMIX",296167,CDM,636,RC,J1644,HCPCS,Outpatient,,,42.49,25.49,,36.12,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34,80.03,,27.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.24,90,,30.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.39,88,,29.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.28,38.24,
GAUZE VASELINE 3 X 9,491400,CDM,270,RC,,,Outpatient,,,42.5,25.5,,36.13,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.01,80.03,,27.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,90,,30.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.66,32.15,,10.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.4,88,,29.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.07,33.11,,11.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.66,38.25,
OXCARBAZEPINE METABOLITE  (MAYO),1880296,CDM,300,RC,80183,HCPCS,Outpatient,,,42.5,25.5,,36.13,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.01,80.03,,27.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.25,90,,30.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.4,88,,29.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.47,38.25,
KEPPRA (LEVETIRACETAM)  (MAYO),1882485,CDM,300,RC,80177,HCPCS,Outpatient,,,42.5,25.5,,36.13,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.01,80.03,,27.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.25,90,,30.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.4,88,,29.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.47,38.25,
LAMICTAL (LAMOTRIGINE)  (MAYO),1882496,CDM,300,RC,80175,HCPCS,Outpatient,,,42.5,25.5,,36.13,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.01,80.03,,27.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.25,90,,30.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.4,88,,29.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.47,38.25,
"M PNEUMONIAE AB, IGG&IGM (MAYO)",1886283,CDM,300,RC,86738,HCPCS,Outpatient,,,42.5,25.5,,36.13,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.01,80.03,,27.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.25,90,,30.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.4,88,,29.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.66,38.25,
HSV TYPE I  AB IGG (MAYO),1886699,CDM,300,RC,86696,HCPCS,Outpatient,,,42.5,25.5,,36.13,85,,28.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.01,80.03,,27.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.25,90,,30.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.4,88,,29.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,38.25,
PANTY HOSE AID,406,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
TUBIGRIP,415,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
SOCK AIDS,427,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
AQUACEL ROPE,432,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
AQUACEL 4 X 4,437,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
FINGER PLATTER,445,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
CUFF NEONATAL BP -DISPOSABLE,49297,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
THICKET,314013,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
SAFETY BELT W/BUCKLE CANVAS,314032,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
SLING ARM LARGE,491208,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
GAUZE TUBE PACKING STRIP VASELINE,491396,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
GAUZE VASELINE INCISION 1 X 8,491403,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
DRESSING COMBIDERM WOUND 4 X 4,491522,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
MASK ANESTHESIA ADULT SIZE 5,491585,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
MASK ANESTHESIA ADULT LARGE SIZE 6,491587,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
MASK ANESTHESIA INFANT SIZE 2,491588,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
SPONGE KERLIX X-RAY DETECTABLE 4.5 X 22,493076,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
SHIELD NIPPLE,493114,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
POWDER STOMAHESIVE 1OZ BOTTLE,493203,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
CATHETER SAFE-LOCK SEALING CAP DIALYSIS,493468,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
TUBE ENDOTRACHEAL 3.0 N/C,493702,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
TUBE NG LEVIN 16FR,493820,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
TUBE NG LEVIN 18FR,493826,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
SET FILTER EXTENSION NEEDLELESS,496383,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
CLAMP KELLEY,497039,CDM,270,RC,,,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.74,32.15,,10.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.15,33.11,,11.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.74,38.48,
RMSF IGM  (MAYO),1886722,CDM,300,RC,86757,HCPCS,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,38.48,
R TYPHI IGM  (MAYO),1886723,CDM,300,RC,86757,HCPCS,Outpatient,,,42.75,25.65,,36.34,85,,29.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.21,80.03,,27.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.48,90,,30.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.62,88,,30.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,38.48,
DRESSING MAXORB 4X4.5 ALGINATE AG EXTRA,498015,CDM,270,RC,,,Outpatient,,,42.81,25.69,,36.39,85,,29.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.76,32.15,,11.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.26,80.03,,27.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.53,90,,30.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.76,32.15,,11.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.81,,,,Other,Not Separately reimbursable,13.76,32.15,,11.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.67,88,,30.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.17,33.11,,11.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.76,38.53,
HEPATITIS B SURFACE ANTIBODY (MAYO),1886291,CDM,300,RC,86706,HCPCS,Outpatient,,,42.81,25.69,,36.39,85,,29.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.26,80.03,,27.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.53,90,,30.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.67,88,,30.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.51,38.53,
MUCOMYST (acetylcysteine) 20% 30ML VIAL,292087,CDM,250,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
KEPPRA (levetiracetam) 100MG/ML SOL 1OZ,292345,CDM,250,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
KEFLEX (cephalexin) 125MG/5ML SUSP:100ML,294021,CDM,250,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
AUGMENTIN (amox/clav) 400MG/5ML : 50 ML,294100,CDM,250,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
GELFOAM 12-7MM,298020,CDM,250,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
B & O (belladonna/opium) SUPP 30MG,299057,CDM,250,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CASTING 3  WHITE DELTA LITE,493136,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  GREEN DELTA-LITE,493183,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  BLACK DELTA-LITE,493187,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  DK BLUE DELTA-LITE,493189,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  LT BLUE DELTA-LITE,493191,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  NEON PINK DELTA-LITE,493193,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  PURPLE DELTA-LITE,493195,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  RED DELTA-LITE,493197,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
TAPE CAST 3  NEON YELLOW DELTA-LITE,493199,CDM,270,RC,,,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
BRETHINE (terbutaline) 1MG/ML AMP,293026,CDM,636,RC,J3105,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43,,,,Other,Not Separately reimbursable,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.3,38.7,
"EPINEPHRINE 1:10,000 21G INJ",293079,CDM,636,RC,J0171,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43,,,,Other,Not Separately reimbursable,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.78,38.7,
GENTAMICIN 60MG /NS 15ML PB,293088,CDM,636,RC,J1580,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,38.7,
FLU VACCINE (influenza) FLUZONE 0.5ML,293279,CDM,636,RC,90655,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.82,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.82,38.7,
NARCAN (naloxone) 2 MG/2 ML INJ,293318,CDM,636,RC,J2310,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.54,38.7,
GENTAMICIN 4MG/ML : variable dose (30ml),293382,CDM,636,RC,J1580,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,38.7,
ADRENALIN (epineph)1:1000 TOPICAL 30ML,297527,CDM,636,RC,J0171,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.78,38.7,
SUBLIMAZE (fentanyl) 20ML VIAL,299063,CDM,636,RC,J3010,HCPCS,Outpatient,,,43,25.8,,36.55,85,,29.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.41,80.03,,27.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,30.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.84,88,,30.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,38.7,
MONISTAT-7 (MICONAZOLE) VAG CREAM  2%,292017,CDM,250,RC,,,Outpatient,,,43.01,25.81,,36.56,85,,29.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.83,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.42,80.03,,27.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.71,90,,30.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.83,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.83,32.15,,11.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.85,88,,30.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.24,33.11,,11.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.83,38.71,
ACCUHIST (bromph/pseudo) DROPS 1OZ,291100,CDM,250,RC,,,Outpatient,,,43.05,25.83,,36.59,85,,29.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.84,32.15,,11.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.45,80.03,,27.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.75,90,,31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.84,32.15,,11.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.84,32.15,,11.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.88,88,,30.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.25,33.11,,11.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.84,38.75,
JELLY SURGILUBE TUBE 4 1/4 OZ,491584,CDM,270,RC,,,Outpatient,,,43.13,25.88,,36.66,85,,29.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.87,32.15,,11.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.52,80.03,,27.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.82,90,,31.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.87,32.15,,11.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.87,32.15,,11.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.95,88,,30.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.28,33.11,,11.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.87,38.82,
SMART CAPNOLINE PLUS ADULT W/O2 009822,49084,CDM,270,RC,,,Outpatient,,,43.25,25.95,,36.76,85,,29.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.61,80.03,,27.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.93,90,,31.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.06,88,,30.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.32,33.11,,11.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.9,38.93,
ATN -UPS,180037,CDM,300,RC,80301,HCPCS,Outpatient,,,43.25,25.95,,36.76,85,,29.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.61,80.03,,27.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.93,90,,31.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.06,88,,30.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.32,33.11,,11.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.9,38.93,
TETANUS TOXIN AB POST-IMM  (MAYO),1886775,CDM,300,RC,86774,HCPCS,Outpatient,,,43.25,25.95,,36.76,85,,29.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.61,80.03,,27.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.93,90,,31.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.06,88,,30.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.61,38.93,
C. DIFF TOXIN A,1887232,CDM,300,RC,87493,HCPCS,Outpatient,,,43.25,25.95,,36.76,85,,29.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.61,80.03,,27.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,38.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.93,90,,31.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.06,88,,30.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.32,33.11,,11.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.9,38.93,
C. DIFF TOXIN B,1887233,CDM,300,RC,87493,HCPCS,Outpatient,,,43.25,25.95,,36.76,85,,29.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.61,80.03,,27.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,38.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.93,90,,31.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.9,32.15,,11.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.06,88,,30.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.32,33.11,,11.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.9,38.93,
MAGNESIUM SULF 50% : 50ML VIAL,293456,CDM,636,RC,J3475,HCPCS,Outpatient,,,43.25,25.95,,36.76,85,,29.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.61,80.03,,27.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.93,90,,31.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.06,88,,30.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.76,38.93,
Blood test to measure average blood glucose levels for past 2-3 months,1883036,CDM,300,RC,83036,HCPCS,Outpatient,,,43.26,25.96,,36.77,85,,29.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.62,80.03,,27.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,38.93,90,,31.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.07,88,,30.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.2,38.93,
CARDENE (nicardipine) 25MG / 10ML INJ,293105,CDM,250,RC,,,Outpatient,,,43.3,25.98,,36.81,85,,29.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.92,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.65,80.03,,27.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.97,90,,31.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.92,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.92,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.1,88,,30.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.34,33.11,,11.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.92,38.97,
AUGMENTIN (amox/clav) 600MG/5ML : 125 ML,294008,CDM,250,RC,,,Outpatient,,,43.3,25.98,,36.81,85,,29.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.92,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.65,80.03,,27.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.97,90,,31.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.92,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.92,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.1,88,,30.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.34,33.11,,11.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.92,38.97,
GELFOAM 2CM,298021,CDM,250,RC,,,Outpatient,,,43.33,26,,36.83,85,,29.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.93,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.68,80.03,,27.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39,90,,31.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.93,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.93,32.15,,11.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.13,88,,30.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.35,33.11,,11.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.93,39,
PENICILLIN 1MU/SW 20ML PB,293133,CDM,636,RC,J2510,HCPCS,Outpatient,,,43.35,26.01,,36.85,85,,29.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.94,32.15,,11.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.69,80.03,,27.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,39.02,90,,31.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.94,32.15,,11.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,13.94,32.15,,11.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.15,88,,30.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.35,33.11,,11.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.94,39.02,
EYE TRAY,14170,CDM,270,RC,,,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.4,33.11,,11.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.15,
SPLINT 3  OPEN THIMBLE,491315,CDM,270,RC,,,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.4,33.11,,11.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.15,
SPLINT 2  OPEN THIMBLE,491316,CDM,270,RC,,,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.4,33.11,,11.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.15,
SPLINT 1 1/2   OPEN THIMBLE,491317,CDM,270,RC,,,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.4,33.11,,11.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.15,
LENS REMOVER SOFT,496537,CDM,270,RC,,,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.4,33.11,,11.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.15,
Test is used to measure the amount of the drug in the blood to determine whether the concentration has reached a therapeutic level and is below the to,1880197,CDM,300,RC,80197,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.25,39.15,
"CALCIUM, IONIZED  (MAYO)",1882330,CDM,300,RC,82330,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.18,39.15,
"MAGNESIUM, FECES, QT  (MAYO)",1884308,CDM,300,RC,83735,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.42,39.15,
ANTI-dsDNA  (MAYO),1886225,CDM,300,RC,86225,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.28,39.15,
TETANUS TOXIN AB PREIMMUNIZATION  (MAYO),1886774,CDM,300,RC,86774,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.61,39.15,
RENAL BIOPSY IMMUNOHISTOL/IF (MAYO),2188346,CDM,310,RC,88350,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,61.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,34.81,61.42,
IF INITIAL (MAYO),2188390,CDM,310,RC,88346,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,34.81,70.93,
DEXTROSTICK,1482948,CDM,450,RC,82962,HCPCS,Outpatient,,,43.5,26.1,,36.98,85,,29.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.81,80.03,,27.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.15,90,,31.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.28,88,,30.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.94,39.15,
DECADRON 1MG/ML INTENSOL (DEXAMETH): 1OZ,292222,CDM,250,RC,,,Outpatient,,,43.52,26.11,,36.99,85,,29.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.83,80.03,,27.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.17,90,,31.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.3,88,,30.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.41,33.11,,11.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.17,
DIPROSONE 0.05% OINT 15GM,297018,CDM,250,RC,,,Outpatient,,,43.52,26.11,,36.99,85,,29.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.83,80.03,,27.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.17,90,,31.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.3,88,,30.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.41,33.11,,11.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.17,
NEODECADRON OPHTH SOLN 5 ML,297724,CDM,250,RC,,,Outpatient,,,43.52,26.11,,36.99,85,,29.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.83,80.03,,27.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.17,90,,31.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,13.99,32.15,,11.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.3,88,,30.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.41,33.11,,11.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.99,39.17,
SENSOR ADHESIVE LNCS O2,49802,CDM,270,RC,,,Outpatient,,,43.54,26.12,,37.01,85,,29.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14,32.15,,11.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,34.85,80.03,,27.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.19,90,,31.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14,32.15,,11.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14,32.15,,11.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.32,88,,30.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.42,33.11,,11.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14,39.19,
BANDAGE ACE 3,49118,CDM,270,RC,,,Outpatient,,,43.75,26.25,,37.19,85,,29.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.07,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.01,80.03,,28.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.38,90,,31.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.07,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.07,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.5,88,,30.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.49,33.11,,11.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.07,39.38,
SPECIAL STAIN,1887019,CDM,300,RC,87207,HCPCS,Outpatient,,,43.75,26.25,,37.19,85,,29.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.01,80.03,,28.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.38,90,,31.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.5,88,,30.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.53,39.38,
CARDIAC REHAB W/OUT EKG MAINT-COUPLE,3996,CDM,943,RC,,,Outpatient,,,43.75,26.25,,37.19,85,,29.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.07,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.01,80.03,,28.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.38,90,,31.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.07,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.07,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.5,88,,30.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.49,33.11,,11.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.07,39.38,
MYCOSTATIN (nystatin ) POWDER 15GM,298053,CDM,250,RC,,,Outpatient,,,43.8,26.28,,37.23,85,,29.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.08,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.05,80.03,,28.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.42,90,,31.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.08,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.08,32.15,,11.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.54,88,,30.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.5,33.11,,11.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.08,39.42,
TUBE ENDOTRACHEAL 4.0 N/C,493705,CDM,270,RC,,,Outpatient,,,44,26.4,,37.4,85,,29.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.15,32.15,,11.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.21,80.03,,28.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.6,90,,31.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.15,32.15,,11.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.15,32.15,,11.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.72,88,,30.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.57,33.11,,11.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.15,39.6,
FORCEP BAYONETTE 5 1/2  DISPOSABLE,4910090,CDM,270,RC,,,Outpatient,,,44,26.4,,37.4,85,,29.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.15,32.15,,11.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.21,80.03,,28.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.6,90,,31.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.15,32.15,,11.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.15,32.15,,11.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.72,88,,30.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.57,33.11,,11.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.15,39.6,
SPOTTED FEVER GRP AB IGG  (MAYO),1886241,CDM,300,RC,86757,HCPCS,Outpatient,,,44,26.4,,37.4,85,,29.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.21,80.03,,28.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.6,90,,31.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.72,88,,30.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,39.6,
SPOTTED FEVER GRP AB IGM  (MAYO),1886242,CDM,300,RC,86757,HCPCS,Outpatient,,,44,26.4,,37.4,85,,29.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.21,80.03,,28.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.6,90,,31.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.72,88,,30.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,39.6,
LOVENOX (enoxaparin) : 30MG INJ,293429,CDM,250,RC,,,Outpatient,,,44.04,26.42,,37.43,85,,29.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.25,80.03,,28.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.64,90,,31.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.76,88,,31.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.58,33.11,,11.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.16,39.64,
DIPRIVAN (propofol) 10MG/ML : 20ML VIAL,293466,CDM,250,RC,,,Outpatient,,,44.04,26.42,,37.43,85,,29.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.25,80.03,,28.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.64,90,,31.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.76,88,,31.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.58,33.11,,11.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.16,39.64,
LOPROX (CICLOPIROX) 0.77% (1%) LOTION,297089,CDM,250,RC,,,Outpatient,,,44.04,26.42,,37.43,85,,29.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.25,80.03,,28.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.64,90,,31.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.76,88,,31.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.58,33.11,,11.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.16,39.64,
CILOXAN (ciprofloxacin)  0.3% OPTH 5ML,297766,CDM,250,RC,,,Outpatient,,,44.04,26.42,,37.43,85,,29.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.25,80.03,,28.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.64,90,,31.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.16,32.15,,11.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.76,88,,31.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.58,33.11,,11.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.16,39.64,
CLAFORAN (cefotaxime) : 1GM VIAL,293351,CDM,636,RC,J0698,HCPCS,Outpatient,,,44.04,26.42,,37.43,85,,29.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.25,80.03,,28.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.64,90,,31.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.76,88,,31.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.8,39.64,
CLAFORAN (cefotaxime) :variable-1g dose,293381,CDM,636,RC,J0698,HCPCS,Outpatient,,,44.04,26.42,,37.43,85,,29.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.25,80.03,,28.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.64,90,,31.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.76,88,,31.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.8,39.64,
Basic metabolic panel,1880007,CDM,300,RC,80048,HCPCS,Outpatient,,,44.08,26.45,,37.47,85,,29.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.28,80.03,,28.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.67,90,,31.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.79,88,,31.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.65,39.67,
RELPAX (eletriptan) 40 MG TAB,291108,CDM,250,RC,,,Outpatient,,,44.2,26.52,,37.57,85,,30.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.21,32.15,,11.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.37,80.03,,28.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.78,90,,31.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.21,32.15,,11.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.21,32.15,,11.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.9,88,,31.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.63,33.11,,11.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.21,39.78,
CAROTENE  (MAYO),1882380,CDM,300,RC,82380,HCPCS,Outpatient,,,44.25,26.55,,37.61,85,,30.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.41,80.03,,28.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.83,90,,31.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.94,88,,31.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.6,39.83,
"FREE CORTISOL, 24-HR URINE  (MAYO)",1882534,CDM,300,RC,82530,HCPCS,Outpatient,,,44.25,26.55,,37.61,85,,30.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.41,80.03,,28.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.83,90,,31.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.94,88,,31.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.02,39.83,
"SODIUM, BODY FLUID  (MAYO)",1882981,CDM,300,RC,84302,HCPCS,Outpatient,,,44.25,26.55,,37.61,85,,30.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.41,80.03,,28.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.83,90,,31.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.94,88,,31.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.35,39.83,
"MAGNESIUM, RBC  (MAYO)",1883736,CDM,300,RC,83735,HCPCS,Outpatient,,,44.25,26.55,,37.61,85,,30.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.41,80.03,,28.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,39.83,90,,31.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.94,88,,31.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.42,39.83,
VERSED (midazolam)SYR: 2MG/ML 5ML DOSE,293176,CDM,250,RC,,,Outpatient,,,44.35,26.61,,37.7,85,,30.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.26,32.15,,11.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.49,80.03,,28.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.92,90,,31.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.26,32.15,,11.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.26,32.15,,11.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.03,88,,31.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.68,33.11,,11.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.26,39.92,
FOSAMAX (alendronate) 70 MG TAB,291010,CDM,250,RC,,,Outpatient,,,44.45,26.67,,37.78,85,,30.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.29,32.15,,11.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.57,80.03,,28.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.01,90,,32.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.29,32.15,,11.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.29,32.15,,11.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.12,88,,31.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.72,33.11,,11.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.29,40.01,
CATH SUCTION 14FR W/STERILE SALINE,49757,CDM,270,RC,,,Outpatient,,,44.5,26.7,,37.83,85,,30.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.31,32.15,,11.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.61,80.03,,28.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.05,90,,32.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.31,32.15,,11.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.31,32.15,,11.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.16,88,,31.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.73,33.11,,11.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.31,40.05,
SEROLOGIC AGG METHOD ID EC1  (MAYO),1882220,CDM,300,RC,87147,HCPCS,Outpatient,,,44.5,26.7,,37.83,85,,30.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.61,80.03,,28.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.05,90,,32.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.16,88,,31.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.61,40.05,
"BODY FLUID, TOTAL PROTEIN  (MAYO)",1882946,CDM,300,RC,84157,HCPCS,Outpatient,,,44.5,26.7,,37.83,85,,30.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.61,80.03,,28.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.05,90,,32.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.16,88,,31.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.61,40.05,
UNDERPANTS MATERNITY 2XL,49176,CDM,270,RC,,,Outpatient,,,44.69,26.81,,37.99,85,,30.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.37,32.15,,11.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.77,80.03,,28.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.22,90,,32.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.37,32.15,,11.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.37,32.15,,11.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.33,88,,31.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.8,33.11,,11.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.37,40.22,
DRESSING STRATASORB 4X4 ISLAND COMPOSIT,498012,CDM,270,RC,,,Outpatient,,,44.69,26.81,,37.99,85,,30.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.37,32.15,,11.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.77,80.03,,28.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.22,90,,32.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.37,32.15,,11.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.37,32.15,,11.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.33,88,,31.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.8,33.11,,11.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.37,40.22,
BORDETELLA PERTUSSIS SMEAR  (MAYO),1887265,CDM,300,RC,87265,HCPCS,Outpatient,,,44.75,26.85,,38.04,85,,30.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.81,80.03,,28.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.21,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.28,90,,32.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.21,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.38,88,,31.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,40.28,
KETALAR ( KETAMINE) 100MG/ML : INJ,293092,CDM,250,RC,,,Outpatient,,,44.81,26.89,,38.09,85,,30.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.41,32.15,,11.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.86,80.03,,28.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.33,90,,32.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.41,32.15,,11.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.41,32.15,,11.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.43,88,,31.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.84,33.11,,11.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.41,40.33,
IMITREX (sumatriptan) 50 MG TABLET,291129,CDM,250,RC,,,Outpatient,,,44.85,26.91,,38.12,85,,30.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.42,32.15,,11.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.89,80.03,,28.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.37,90,,32.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.42,32.15,,11.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.42,32.15,,11.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.47,88,,31.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.85,33.11,,11.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.42,40.37,
KIT WOUND DRAIN 15 FR 3/16  400CC,4900402,CDM,270,RC,,,Outpatient,,,44.88,26.93,,38.15,85,,30.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.43,32.15,,11.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.92,80.03,,28.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.39,90,,32.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.43,32.15,,11.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.43,32.15,,11.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.49,88,,31.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.86,33.11,,11.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.43,40.39,
"OSMOLALITY, FECAL  (MAYO)",1883931,CDM,300,RC,83930,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.32,40.5,
BODY FLUID CELL COUNT AND DIFF (NEGMC),1884901,CDM,300,RC,89051,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.71,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.71,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.21,40.5,
CRYSTAL ANALYSIS (ANMED),1884902,CDM,300,RC,89060,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.47,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.47,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.99,40.5,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,1885544,CDM,300,RC,87205,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.95,40.5,
"..FECAL FAT STAIN, QL",1889125,CDM,300,RC,89125,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.43,40.5,
Use of massage,311011,CDM,420,RC,97124,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,33.11,,11.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.47,40.5,
A type of physical therapy,311017,CDM,420,RC,97116,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,33.11,,11.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.47,40.5,
P/T DEBRIDEMENT MEDIUM BURN,3112052,CDM,420,RC,97139,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.47,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,33.11,,11.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.47,40.5,
VANCOMYCIN 1GM VIAL (for oral admin),293576,CDM,636,RC,J3370,HCPCS,Outpatient,,,45,27,,38.25,85,,30.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.01,80.03,,28.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,90,,32.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.6,88,,31.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,40.5,
ZOSYN 3.375GM VIAL - RX COMPOUND,293400,CDM,250,RC,,,Outpatient,,,45.03,27.02,,38.28,85,,30.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.48,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.04,80.03,,28.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.53,90,,32.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.48,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.48,32.15,,11.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.63,88,,31.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.91,33.11,,11.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.48,40.53,
VAP-CHOLESTEROL  (MAYO),1883701,CDM,300,RC,83701,HCPCS,Outpatient,,,45.05,27.03,,38.29,85,,30.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.05,80.03,,28.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,34.53,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.55,90,,32.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.53,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.64,88,,31.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.21,40.55,
HAND MITTEN FLEXIBLE COOLKNIT BUCKLE,49660,CDM,270,RC,,,Outpatient,,,45.25,27.15,,38.46,85,,30.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.21,80.03,,28.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.73,90,,32.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.82,88,,31.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.98,33.11,,11.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.55,40.73,
POUCH SUR-FIT DRAINABLE 1 3/4,493220,CDM,270,RC,,,Outpatient,,,45.25,27.15,,38.46,85,,30.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.21,80.03,,28.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.73,90,,32.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.82,88,,31.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.98,33.11,,11.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.55,40.73,
DRAIN PENROSE 18 X0.25  LATEX STERILE,493904,CDM,270,RC,,,Outpatient,,,45.25,27.15,,38.46,85,,30.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.21,80.03,,28.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.73,90,,32.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.82,88,,31.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.98,33.11,,11.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.55,40.73,
DRAIN PENROSE 18 X0.625  LATEX STERILE,493910,CDM,270,RC,,,Outpatient,,,45.25,27.15,,38.46,85,,30.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.21,80.03,,28.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.73,90,,32.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.55,32.15,,11.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.82,88,,31.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.98,33.11,,11.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.55,40.73,
ANUSOL-HC 2.5%(hydrocortisone )CRM 1 OZ,297004,CDM,250,RC,,,Outpatient,,,45.32,27.19,,38.52,85,,30.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.57,32.15,,11.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.27,80.03,,29.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.79,90,,32.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.57,32.15,,11.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.57,32.15,,11.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.88,88,,31.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.01,33.11,,12.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.57,40.79,
SHEET ABSORBENT & IMPERVIOUS,49009,CDM,270,RC,,,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,33.11,,12.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.63,40.95,
SHEET ABSORBENT & IMPERVIOUS,490008,CDM,270,RC,,,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,33.11,,12.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.63,40.95,
TRAY TRACH CARE,493694,CDM,270,RC,,,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.63,32.15,,11.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,33.11,,12.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.63,40.95,
CLOZARIL (CLOZAPINE)  (MAYO),1880156,CDM,300,RC,80159,HCPCS,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.55,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.55,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.18,40.95,
PHENOBARBITAL,1882205,CDM,300,RC,80184,HCPCS,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.84,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.41,40.95,
VITAMIN E  (MAYO),1884241,CDM,300,RC,84446,HCPCS,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.46,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.46,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.36,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.83,40.95,
Blood test to evaluate thyroid function,1884480,CDM,300,RC,84480,HCPCS,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.46,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.46,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.03,40.95,
"HERPES SIMPLEX, IGM, EIA  (MAYO)",1886698,CDM,300,RC,86694,HCPCS,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,40.95,
".WEST NILE VIRUS, IGG  (MAYO)",1886793,CDM,300,RC,86789,HCPCS,Outpatient,,,45.5,27.3,,38.68,85,,30.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.41,80.03,,29.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,40.95,90,,32.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,88,,32.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,40.95,
AMPICILLIN 500MG / 50ML NS PB,293281,CDM,636,RC,J0290,HCPCS,Outpatient,,,45.57,27.34,,38.73,85,,30.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.47,80.03,,29.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.01,90,,32.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.1,88,,32.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,41.01,
OINTMENT PROTECTIVE VESTA ALOE,491513,CDM,270,RC,,,Outpatient,,,45.75,27.45,,38.89,85,,31.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.61,80.03,,29.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.18,90,,32.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.26,88,,32.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.15,33.11,,12.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.71,41.18,
CLEANSER SHUR-CLENS WOUND 20ML,491515,CDM,270,RC,,,Outpatient,,,45.75,27.45,,38.89,85,,31.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.61,80.03,,29.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.18,90,,32.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.26,88,,32.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.15,33.11,,12.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.71,41.18,
SNARE MASTER,498826,CDM,270,RC,,,Outpatient,,,45.75,27.45,,38.89,85,,31.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.61,80.03,,29.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.18,90,,32.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.26,88,,32.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.15,33.11,,12.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.71,41.18,
. 5% PLASMA PROTEIN,2096393,CDM,390,RC,,,Outpatient,,,45.75,27.45,,38.89,85,,31.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.61,80.03,,29.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.18,90,,32.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.26,88,,32.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.15,33.11,,12.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.71,41.18,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",3932,CDM,430,RC,97530,HCPCS,Outpatient,,,45.76,27.46,,38.9,85,,31.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.62,80.03,,29.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,41.18,90,,32.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,14.71,32.15,,11.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.27,88,,32.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.15,33.11,,12.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.71,41.18,
NM TC 99/M KIT,2932295,CDM,343,RC,A9504,HCPCS,Outpatient,,,45.84,27.5,,38.96,85,,31.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.74,32.15,,11.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.69,80.03,,29.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.26,90,,33.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.74,32.15,,11.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.74,32.15,,11.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.34,88,,32.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.18,33.11,,12.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.74,41.26,
ERYTHROMYCIN : 1GM VIAL,293354,CDM,636,RC,J1364,HCPCS,Outpatient,,,45.84,27.5,,38.96,85,,31.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.69,80.03,,29.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,85.31,102,,,fee schedule,Pays at 102% of CMS APC rate,41.26,90,,33.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.31,100,,,fee schedule,Pays at 100% of CMS APC rate,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.34,88,,32.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,86.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.69,83.64,
IMMUNE SERUM GLOBULUM HUM,296026,CDM,636,RC,J1566,HCPCS,Outpatient,,,45.84,27.5,,38.96,85,,31.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.69,80.03,,29.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,78.09,102,,,fee schedule,Pays at 102% of CMS APC rate,41.26,90,,33.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.09,100,,,fee schedule,Pays at 100% of CMS APC rate,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.34,88,,32.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.69,76.57,
CLEOCIN  (clindamycin) 900MG/D5W 50ML PB,293039,CDM,250,RC,S0077,HCPCS,Outpatient,,,45.87,27.52,,38.99,85,,31.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.75,32.15,,11.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.71,80.03,,29.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.28,90,,33.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.75,32.15,,11.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.75,32.15,,11.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.37,88,,32.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.19,33.11,,12.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.75,41.28,
Blood test to measure a type of thyroid hormone,1884435,CDM,300,RC,84436,HCPCS,Outpatient,,,45.92,27.55,,39.03,85,,31.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.75,80.03,,29.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.33,90,,33.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.41,88,,32.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.65,41.33,
T3 UPTAKE,1884479,CDM,300,RC,84479,HCPCS,Outpatient,,,45.92,27.55,,39.03,85,,31.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.75,80.03,,29.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.33,90,,33.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.41,88,,32.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.14,41.33,
Blood test to evaluate thyroid function,1884483,CDM,300,RC,84439,HCPCS,Outpatient,,,45.92,27.55,,39.03,85,,31.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.75,80.03,,29.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.33,90,,33.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.41,88,,32.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.34,41.33,
DRESSING EXUDERM 4X3.6 ODORSHIELD,498010,CDM,270,RC,,,Outpatient,,,45.94,27.56,,39.05,85,,31.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.77,32.15,,11.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.77,80.03,,29.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.35,90,,33.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.77,32.15,,11.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.77,32.15,,11.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.43,88,,32.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.21,33.11,,12.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.77,41.35,
CONNECTOR 5 IN 1 STERILE,49816,CDM,270,RC,,,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
TUBE NG LEVIN 14FR,493814,CDM,270,RC,,,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
ALCOHOL BREATH CONFIRMATION,1882076,CDM,300,RC,82075,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
"CHLORIDE, BODY FLUID  (MAYO)",1882982,CDM,300,RC,82438,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.15,41.4,
"POTASSIUM, BODY FLUID  (MAYO)",1882983,CDM,300,RC,84999,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
PROTEIN S AG FREE (MAYO),1885310,CDM,300,RC,85306,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.27,41.4,
CHLORAPREP 26ML APPLICATOR,4999902,CDM,270,RC,,,Outpatient,,,46.25,27.75,,39.31,85,,31.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.01,80.03,,29.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.63,90,,33.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.7,88,,32.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.31,33.11,,12.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.87,41.63,
Echo with doppler,3012,CDM,480,RC,93320,HCPCS,Outpatient,,,46.25,27.75,,39.31,85,,31.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.01,80.03,,29.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.63,90,,33.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.7,88,,32.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.31,33.11,,12.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.87,41.63,
Echo with doppler,4019,CDM,480,RC,93320,HCPCS,Outpatient,,,46.25,27.75,,39.31,85,,31.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.01,80.03,,29.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.63,90,,33.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.7,88,,32.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.31,33.11,,12.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.87,41.63,
Echo with doppler,15012,CDM,480,RC,93320,HCPCS,Outpatient,,,46.25,27.75,,39.31,85,,31.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.01,80.03,,29.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.63,90,,33.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.87,32.15,,11.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.7,88,,32.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.31,33.11,,12.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.87,41.63,
SET EXTENSION W/1.2 MICRON FILTER 16,492149,CDM,270,RC,,,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.4,33.11,,12.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.95,41.85,
THYROID PEROXIDASE AB  (MAYO),1881765,CDM,300,RC,86376,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.3,41.85,
"..ALCOHOL, ETHANOL URINE",1882056,CDM,300,RC,80320,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.59,41.85,
ALPHA 1 ANTITRYPSIN PHENOTYPING  (MAYO),1882104,CDM,300,RC,82104,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.18,41.85,
"ANGIOTENSIN CONV ENZYME, ACE  (MAYO)",1882164,CDM,300,RC,82164,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,41.85,
"CHROMIUM, SERUM  (MAYO)",1882527,CDM,300,RC,82495,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.68,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.68,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.51,41.85,
MYOGLOBIN SERUM  (MAYO),1883873,CDM,300,RC,83874,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.17,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.17,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.24,41.85,
RPR TITER.S (MAYO),1884912,CDM,300,RC,86593,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.4,33.11,,12.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.95,41.85,
MEDICAL NUTRITION THERAPY / GRP / 30 MIN,97804,CDM,942,RC,97804,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.08,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.4,33.11,,12.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.95,41.85,
DIABETES SELF-MGMT TRAIN / GRP / 30 MIN,98961,CDM,942,RC,98961,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.4,33.11,,12.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.95,41.85,
"C3 IF, RENAL  (MAYO)",2188347,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"FIBRINOGEN IF, RENAL   (MAYO)",2188349,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"IGA IF, RENAL   (MAYO)",2188350,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"IGM IF, RENAL   (MAYO)",2188351,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"LAMBDA IF, RENAL   (MAYO)",2188352,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"IGG IF, RENAL   (MAYO)",2188357,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"KAPPA IF, RENAL   (MAYO)",2188358,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"C1Q IF, RENAL   (MAYO)",2188359,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"ALBUMIN IF, RENAL   (MAYO)",2188361,CDM,310,RC,88346,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.41,70.93,
"IF, EACH AB, IND; C4D TRANSPLANTS (MAYO)",2188362,CDM,310,RC,88347,HCPCS,Outpatient,,,46.75,28.05,,39.74,85,,31.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.03,32.15,,12.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.41,80.03,,29.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.08,90,,33.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.03,32.15,,12.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.03,32.15,,12.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.14,88,,32.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.48,33.11,,12.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.03,42.08,
MUCOMYST (ACETYLCYSTEINE) 20% 10ML VIAL,292085,CDM,250,RC,,,Outpatient,,,46.87,28.12,,39.84,85,,31.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.07,32.15,,12.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.51,80.03,,30.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.18,90,,33.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.07,32.15,,12.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.07,32.15,,12.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.25,88,,33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.52,33.11,,12.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.07,42.18,
PRED FORTE (PREDNISOLONE) OPHTH SOL:15ML,297728,CDM,250,RC,,,Outpatient,,,46.87,28.12,,39.84,85,,31.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.07,32.15,,12.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.51,80.03,,30.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.18,90,,33.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.07,32.15,,12.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.07,32.15,,12.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.25,88,,33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.52,33.11,,12.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.07,42.18,
SET PUMP 15 DROP 3 CARESITE,492141,CDM,270,RC,,,Outpatient,,,46.95,28.17,,39.91,85,,31.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,32.15,,12.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.57,80.03,,30.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.26,90,,33.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,32.15,,12.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.09,32.15,,12.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.32,88,,33.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,33.11,,12.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.09,42.26,
GENTAMICIN 80MG / NS 20ML PB,293227,CDM,636,RC,J1580,HCPCS,Outpatient,,,47,28.2,,39.95,85,,31.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.61,80.03,,30.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.3,90,,33.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.36,88,,33.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,42.3,
Blood test to measure B-12,188405,CDM,300,RC,82607,HCPCS,Outpatient,,,47.13,28.28,,40.06,85,,32.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.72,80.03,,30.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.42,90,,33.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.47,88,,33.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,42.42,
"FLUOXETINE, PROZAC  (MAYO)",1882490,CDM,300,RC,80332,HCPCS,Outpatient,,,47.25,28.35,,40.16,85,,32.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.19,32.15,,12.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.81,80.03,,30.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.53,90,,34.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.19,32.15,,12.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.19,32.15,,12.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.58,88,,33.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.64,33.11,,12.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.19,42.53,
XARELTO (rivaroxaban) 20MG TAB,29139,CDM,250,RC,,,Outpatient,,,47.28,28.37,,40.19,85,,32.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.2,32.15,,12.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,80.03,,30.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.55,90,,34.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.2,32.15,,12.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.2,32.15,,12.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.61,88,,33.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.65,33.11,,12.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.2,42.55,
XARELTO (rivaroxaban) 15MG TAB,29266,CDM,250,RC,,,Outpatient,,,47.28,28.37,,40.19,85,,32.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.2,32.15,,12.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.84,80.03,,30.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.55,90,,34.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.2,32.15,,12.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.2,32.15,,12.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.61,88,,33.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.65,33.11,,12.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.2,42.55,
WRIST BRACE FUTURO,314012,CDM,270,RC,,,Outpatient,,,47.3,28.38,,40.21,85,,32.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.21,32.15,,12.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.85,80.03,,30.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.57,90,,34.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.21,32.15,,12.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.21,32.15,,12.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.62,88,,33.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.66,33.11,,12.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.21,42.57,
WOUND MANAGEMENT II,3922,CDM,490,RC,11040,HCPCS,Outpatient,,,47.3,28.38,,40.21,85,,32.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.21,32.15,,12.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.85,80.03,,30.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.57,90,,34.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.21,32.15,,12.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.21,32.15,,12.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.62,88,,33.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.66,33.11,,12.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.21,42.57,
DIFLUCAN  (fluconazole) 200MG /100ML PB,293308,CDM,636,RC,J1450,HCPCS,Outpatient,,,47.3,28.38,,40.21,85,,32.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,37.85,80.03,,30.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.57,90,,34.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.62,88,,33.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.31,42.57,
BRETH-AIRE INH,292097,CDM,250,RC,,,Outpatient,,,47.38,28.43,,40.27,85,,32.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.92,80.03,,30.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.64,90,,34.11,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.69,88,,33.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.69,33.11,,12.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.23,42.64,
CHLOROMYCETIN  150MG/5ML SUSP : 1OZ,294011,CDM,250,RC,,,Outpatient,,,47.38,28.43,,40.27,85,,32.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.92,80.03,,30.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.64,90,,34.11,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.69,88,,33.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.69,33.11,,12.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.23,42.64,
LOTRIMIN CRM (CLOTRIMAZOLE) 1% 90GM,297084,CDM,250,RC,,,Outpatient,,,47.38,28.43,,40.27,85,,32.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.92,80.03,,30.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.64,90,,34.11,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.23,32.15,,12.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.69,88,,33.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.69,33.11,,12.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.23,42.64,
URINARY LEG DRAIN BAG LARGE,49062,CDM,270,RC,,,Outpatient,,,47.5,28.5,,40.38,85,,32.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.27,32.15,,12.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.01,80.03,,30.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,90,,34.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.27,32.15,,12.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.27,32.15,,12.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.8,88,,33.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.73,33.11,,12.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.27,42.75,
"PH, STOOL  (MAYO)",1881098,CDM,300,RC,83986,HCPCS,Outpatient,,,47.5,28.5,,40.38,85,,32.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.01,80.03,,30.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.75,90,,34.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.8,88,,33.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.5,42.75,
"ELECTRO, PROTEIN  SPEP (MAYO)",1884200,CDM,300,RC,84165,HCPCS,Outpatient,,,47.5,28.5,,40.38,85,,32.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.01,80.03,,30.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.75,90,,34.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.8,88,,33.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.51,42.75,
Blood test to monitor breast cancer,1886309,CDM,300,RC,86300,HCPCS,Outpatient,,,47.5,28.5,,40.38,85,,32.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.01,80.03,,30.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.75,90,,34.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.8,88,,33.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.16,42.75,
"EBV IGG, AB EARLY AG  (MAYO)",1886665,CDM,300,RC,86663,HCPCS,Outpatient,,,47.5,28.5,,40.38,85,,32.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.01,80.03,,30.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.75,90,,34.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.8,88,,33.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.5,42.75,
AMMONIA,1882140,CDM,300,RC,82140,HCPCS,Outpatient,,,47.56,28.54,,40.43,85,,32.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.06,80.03,,30.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.8,90,,34.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.85,88,,33.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.44,42.8,
"SED RATE, WESTERGREN",1885651,CDM,300,RC,85651,HCPCS,Outpatient,,,47.56,28.54,,40.43,85,,32.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.06,80.03,,30.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.8,90,,34.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.85,88,,33.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.46,42.8,
RSV,1886261,CDM,300,RC,86756,HCPCS,Outpatient,,,47.56,28.54,,40.43,85,,32.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.06,80.03,,30.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.8,90,,34.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.85,88,,33.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.21,42.8,
Test of body fluid other than blood to assess for bacteria,1887073,CDM,300,RC,87070,HCPCS,Outpatient,,,47.56,28.54,,40.43,85,,32.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.06,80.03,,30.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.8,90,,34.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.85,88,,33.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,42.8,
CATH MALE EXTERNAL GERIATRIC/PEDIATRIC,49415,CDM,270,RC,,,Outpatient,,,47.75,28.65,,40.59,85,,32.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.21,80.03,,30.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.98,90,,34.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.02,88,,33.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.81,33.11,,12.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.35,42.98,
CATH MALE EXTERNAL MEDIUM,49416,CDM,270,RC,,,Outpatient,,,47.75,28.65,,40.59,85,,32.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.21,80.03,,30.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.98,90,,34.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.02,88,,33.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.81,33.11,,12.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.35,42.98,
PROTECTOR EYE IGUARD ADULT STERILE,491600,CDM,270,RC,,,Outpatient,,,47.75,28.65,,40.59,85,,32.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.21,80.03,,30.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.98,90,,34.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.75,,,,Other,Not Separately reimbursable,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.02,88,,33.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.81,33.11,,12.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.35,42.98,
CANISTER SUCTION D/C TISSUE TRAP,491810,CDM,270,RC,,,Outpatient,,,47.75,28.65,,40.59,85,,32.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.21,80.03,,30.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.98,90,,34.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.75,,,,Other,Not Separately reimbursable,15.35,32.15,,12.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.02,88,,33.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.81,33.11,,12.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.35,42.98,
Blood test to determine the concentration of lead in the blood,1883645,CDM,300,RC,83655,HCPCS,Outpatient,,,47.75,28.65,,40.59,85,,32.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.21,80.03,,30.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,42.98,90,,34.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.02,88,,33.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10,42.98,
Blood test to determine the concentration of lead in the blood,1883655,CDM,300,RC,83655,HCPCS,Outpatient,,,47.81,28.69,,40.64,85,,32.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.26,80.03,,30.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,43.03,90,,34.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.07,88,,33.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10,43.03,
ANA  (MAYO),1886038,CDM,300,RC,86038,HCPCS,Outpatient,,,47.81,28.69,,40.64,85,,32.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.26,80.03,,30.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,43.03,90,,34.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.07,88,,33.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.2,43.03,
PEDIAZOLE (ery/sulfisox) SUSP : 100ML,294028,CDM,250,RC,,,Outpatient,,,47.9,28.74,,40.72,85,,32.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.33,80.03,,30.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.11,90,,34.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.9,,,,Other,Not Separately reimbursable,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.15,88,,33.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.86,33.11,,12.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.4,43.11,
TEGOPEN 125MG/5ML SY : 200ML,294031,CDM,250,RC,,,Outpatient,,,47.9,28.74,,40.72,85,,32.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.33,80.03,,30.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.11,90,,34.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.9,,,,Other,Not Separately reimbursable,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.15,88,,33.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.86,33.11,,12.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.4,43.11,
DIPROLENE-AF 0.05% CRM 15GM,297088,CDM,250,RC,,,Outpatient,,,47.9,28.74,,40.72,85,,32.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.33,80.03,,30.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.11,90,,34.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.9,,,,Other,Not Separately reimbursable,15.4,32.15,,12.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.15,88,,33.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.86,33.11,,12.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.4,43.11,
ZOMIG (zolmitriptan) 5MG TAB,29642,CDM,250,RC,,,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48,,,,Other,Not Separately reimbursable,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
GLUTOSE  (oral glucose) 15 GM GEL,293243,CDM,250,RC,,,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48,,,,Other,Not Separately reimbursable,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
D 2.5% 1/4NS  1000ML,296200,CDM,258,RC,,,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48,,,,Other,Not Separately reimbursable,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
D 12.5% W 250ML,296244,CDM,258,RC,,,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48,,,,Other,Not Separately reimbursable,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
DRESSING FOAM 6 X6  HYDRO BLUE,498053,CDM,270,RC,,,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48,,,,Other,Not Separately reimbursable,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
KENALOG (triamcinolone) 40MG INJ,293091,CDM,636,RC,J3301,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48,,,,Other,Not Separately reimbursable,1.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.19,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.16,43.2,
ANCEF (cefazolin)  2GM/ 50ML D5W,293246,CDM,636,RC,J0690,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48,,,,Other,Not Separately reimbursable,0.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.73,43.2,
ZINACEF (cefuroxime) 750MG /SW 10ML PB,293298,CDM,636,RC,J0697,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48,,,,Other,Not Separately reimbursable,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.87,43.2,
VANCOCIN (vancomycin) : 1GM VIAL,293388,CDM,636,RC,J3370,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,43.2,
ZINACEF (cefuroxime) :1.5GM VIAL,293392,CDM,636,RC,J0697,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48,,,,Other,Not Separately reimbursable,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.87,43.2,
BLADE CLIPPER SURGICAL,49059,CDM,270,RC,,,Outpatient,,,48.13,28.88,,40.91,85,,32.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.47,32.15,,12.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.52,80.03,,30.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.32,90,,34.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.47,32.15,,12.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.13,,,,Other,Not Separately reimbursable,15.47,32.15,,12.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.35,88,,33.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.94,33.11,,12.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.47,43.32,
ACTONEL (risedronate) 35 MG TAB,291032,CDM,250,RC,,,Outpatient,,,48.15,28.89,,40.93,85,,32.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.48,32.15,,12.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.53,80.03,,30.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.34,90,,34.67,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.48,32.15,,12.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.15,,,,Other,Not Separately reimbursable,15.48,32.15,,12.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.37,88,,33.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.94,33.11,,12.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.48,43.34,
VALIUM (diazepam) 10MG/2ML INJ,293203,CDM,636,RC,J3360,HCPCS,Outpatient,,,48.15,28.89,,40.93,85,,32.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.53,80.03,,30.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.34,90,,34.67,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.15,,,,Other,Not Separately reimbursable,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.37,88,,33.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.48,43.34,
GASTROGRAFIN 120ML BTL,225036,CDM,255,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
SUTURE CHROMIC GUT 4/0 18  P-13,496360,CDM,270,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
SUTURE MONOSOF 4.0 BLACK 18  P-12,4903351,CDM,270,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
SUTURE MONOSOF BLACK 6.0 18  PC-13 06Q,4993349,CDM,270,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
SUTURE MONOSOF BLACK 3.0 30  C-14,4993350,CDM,270,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
SUTURE MONOSOF 5.0 18  BLACK P-12,4993352,CDM,270,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
SUTURE MONOSOF BLACK 6/0 18  C-1,4993353,CDM,270,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
SUTURE MONOSOF 5.0 18  BLACK P-12,4993354,CDM,270,RC,,,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.25,,,,Other,Not Separately reimbursable,15.51,32.15,,12.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.98,33.11,,12.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.51,43.43,
Manual urinalysis test with examination without using microscope,1881005,CDM,300,RC,81002,HCPCS,Outpatient,,,48.25,28.95,,41.01,85,,32.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.61,80.03,,30.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.54,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,43.43,90,,34.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.54,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.46,88,,33.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.31,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.21,43.43,
MONAGHAN MDI SPACER,30242,CDM,270,RC,,,Outpatient,,,48.38,29.03,,41.12,85,,32.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.55,32.15,,12.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.72,80.03,,30.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.54,90,,34.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.55,32.15,,12.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.38,,,,Other,Not Separately reimbursable,15.55,32.15,,12.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.57,88,,34.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.02,33.11,,12.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.55,43.54,
.HEAT MOISTURE EXCHANGER,30261,CDM,270,RC,,,Outpatient,,,48.38,29.03,,41.12,85,,32.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.55,32.15,,12.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.72,80.03,,30.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.54,90,,34.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.55,32.15,,12.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.38,,,,Other,Not Separately reimbursable,15.55,32.15,,12.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.57,88,,34.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.02,33.11,,12.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.55,43.54,
SMART CAPNOLINE PEDIATRIC W/O2 007269,49099,CDM,270,RC,,,Outpatient,,,48.5,29.1,,41.23,85,,32.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.81,80.03,,31.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.65,90,,34.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.5,,,,Other,Not Separately reimbursable,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.68,88,,34.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.06,33.11,,12.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.59,43.65,
P/T GROUP  THERAPY,450,CDM,420,RC,97150,HCPCS,Outpatient,,,48.5,29.1,,41.23,85,,32.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.81,80.03,,31.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.37,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,43.65,90,,34.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.37,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.68,88,,34.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.06,33.11,,12.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.59,43.65,
O/T GROUP THERAPY,452,CDM,430,RC,97150,HCPCS,Outpatient,,,48.5,29.1,,41.23,85,,32.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.81,80.03,,31.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.37,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,43.65,90,,34.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.37,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,15.59,32.15,,12.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.68,88,,34.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.06,33.11,,12.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.59,43.65,
AUGMENTIN (AMOX/CLAV) 125MG/5ML: 75ML,294063,CDM,250,RC,,,Outpatient,,,48.67,29.2,,41.37,85,,33.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.95,80.03,,31.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.8,90,,35.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.67,,,,Other,Not Separately reimbursable,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.83,88,,34.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.11,33.11,,12.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.65,43.8,
ANTIVENOM-BLK WED SPIDER,296003,CDM,250,RC,,,Outpatient,,,48.67,29.2,,41.37,85,,33.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.95,80.03,,31.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.8,90,,35.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.67,,,,Other,Not Separately reimbursable,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.83,88,,34.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.11,33.11,,12.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.65,43.8,
GELFOAM SIZE 100,298027,CDM,250,RC,,,Outpatient,,,48.67,29.2,,41.37,85,,33.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.95,80.03,,31.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.8,90,,35.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.67,,,,Other,Not Separately reimbursable,15.65,32.15,,12.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.83,88,,34.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.11,33.11,,12.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.65,43.8,
ZOFRAN (ondansetron) 4MG TAB,29658,CDM,250,RC,J2405,HCPCS,Outpatient,,,48.75,29.25,,41.44,85,,33.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.01,80.03,,31.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.88,90,,35.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.75,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.9,88,,34.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,43.88,
ENEMA PHOSPHATE,491044,CDM,270,RC,,,Outpatient,,,48.75,29.25,,41.44,85,,33.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.67,32.15,,12.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.01,80.03,,31.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.88,90,,35.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.67,32.15,,12.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.75,,,,Other,Not Separately reimbursable,15.67,32.15,,12.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.9,88,,34.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.14,33.11,,12.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.67,43.88,
VON WILLEBRAND FACTOR AG  (MAYO),1885246,CDM,300,RC,85246,HCPCS,Outpatient,,,48.75,29.25,,41.44,85,,33.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.01,80.03,,31.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,43.88,90,,35.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.9,88,,34.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.85,43.88,
"LEGIONELLA PNEUMO AB, SERUM  (MAYO)",1886258,CDM,300,RC,86713,HCPCS,Outpatient,,,48.75,29.25,,41.44,85,,33.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.01,80.03,,31.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,43.88,90,,35.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.9,88,,34.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.25,43.88,
MAXIPIME (CEFEPIME) : 1GM VIAL,293877,CDM,636,RC,J0692,HCPCS,Outpatient,,,48.79,29.27,,41.47,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.91,90,,35.13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.79,,,,Other,Not Separately reimbursable,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.15,33.11,,12.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.91,
NOT CHARGEABLE ITEM,3591,CDM,420,RC,97504,HCPCS,Outpatient,,,48.8,29.28,,41.48,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.92,90,,35.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.8,,,,Other,Not Separately reimbursable,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.16,33.11,,12.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.92,
HAND SPLINT FIT/CONSTRUCTION I,387,CDM,430,RC,97504,HCPCS,Outpatient,,,48.8,29.28,,41.48,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.92,90,,35.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.8,,,,Other,Not Separately reimbursable,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.16,33.11,,12.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.92,
Occupational therapy,593007,CDM,430,RC,97535,HCPCS,Outpatient,,,48.8,29.28,,41.48,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,43.92,90,,35.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.16,33.11,,12.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.92,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",593010,CDM,430,RC,97110,HCPCS,Outpatient,,,48.8,29.28,,41.48,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,43.92,90,,35.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.16,33.11,,12.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.92,
O/T PARAFFIN BATH,593016,CDM,430,RC,97018,HCPCS,Outpatient,,,48.8,29.28,,41.48,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.47,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,43.92,90,,35.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.47,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.16,33.11,,12.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.92,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",593020,CDM,430,RC,97110,HCPCS,Outpatient,,,48.8,29.28,,41.48,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,43.92,90,,35.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.16,33.11,,12.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.92,
O/T SPLINT ADJUST I - 15 MINUTES,593030,CDM,430,RC,97504,HCPCS,Outpatient,,,48.8,29.28,,41.48,85,,33.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.05,80.03,,31.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.92,90,,35.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.8,,,,Other,Not Separately reimbursable,15.69,32.15,,12.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,88,,34.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.16,33.11,,12.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.69,43.92,
CARDIZEM DRIP (diltiazem) 125MG/125ML NS,293828,CDM,250,RC,,,Outpatient,,,48.84,29.3,,41.51,85,,33.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.7,32.15,,12.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.09,80.03,,31.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.96,90,,35.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.7,32.15,,12.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.84,,,,Other,Not Separately reimbursable,15.7,32.15,,12.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.98,88,,34.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.17,33.11,,12.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.7,43.96,
TUBE ENDOTRACHEAL 2.0 N/C,493703,CDM,270,RC,,,Outpatient,,,49,29.4,,41.65,85,,33.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.75,32.15,,12.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.21,80.03,,31.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.1,90,,35.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.75,32.15,,12.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49,,,,Other,Not Separately reimbursable,15.75,32.15,,12.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.12,88,,34.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.22,33.11,,12.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.75,44.1,
"TETANUS ANTITOXOID AB, IGG  (MAYO)",1882217,CDM,300,RC,86317,HCPCS,Outpatient,,,49,29.4,,41.65,85,,33.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.21,80.03,,31.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.1,90,,35.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.12,88,,34.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.09,44.1,
NITROLINGUAL SPRAY 13.8 GM,29395,CDM,250,RC,,,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.19,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
NAVANE CONC (THIOTHIXENE) 1OZ,292247,CDM,250,RC,,,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.19,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
LOTRIMIN CRM (CLOTRIMAZOLE) 1% 45GM,297075,CDM,250,RC,,,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.19,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
D5W W/KCL 20 1000ML,296163,CDM,258,RC,S5012,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
"HEPARIN 20,000/D5W 500ML",296166,CDM,258,RC,,,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
D5 1/2 NS W/KCL 20 MEQ/LITER,296207,CDM,258,RC,S5013,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
D5 1/2 NS W/KCL 30 MEQ/LITER,296208,CDM,258,RC,S5013,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
D5 1/2 NS W/KCL 40MEQ/LITER,296209,CDM,258,RC,S5013,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
D5NS W/KCL 20 MEQ/LITER,296219,CDM,258,RC,S5012,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
D5 LR W/KCL 20MEQ  1000ML,296231,CDM,258,RC,J7120,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.45,44.27,
D5W NORMOSOL R pH 7.4 1000ML,296272,CDM,258,RC,J7060,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.63,44.27,
NS W/ KCL 20:1000ML,296297,CDM,258,RC,J7030,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.58,44.27,
D5 1/2 NS W KCL 10MEQ  1000ML,296210,CDM,636,RC,J3490,HCPCS,Outpatient,,,49.19,29.51,,41.81,85,,33.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.81,32.15,,12.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.29,88,,34.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.29,33.11,,13.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.81,44.27,
"Blood test, lipids (cholesterol and triglycerides)",1883716,CDM,300,RC,80061,HCPCS,Outpatient,,,49.2,29.52,,41.82,85,,33.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.37,80.03,,31.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.28,90,,35.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.3,88,,34.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.36,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.85,44.28,
Single view,22385,CDM,320,RC,71045,HCPCS,Outpatient,,,49.35,29.61,,41.95,85,,33.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.87,32.15,,12.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.49,80.03,,31.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,44.42,90,,35.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.87,32.15,,12.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,15.87,32.15,,12.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.43,88,,34.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.34,33.11,,13.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.87,44.42,
AVC VAG SUPP,292012,CDM,250,RC,,,Outpatient,,,49.7,29.82,,42.25,85,,33.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.98,32.15,,12.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.77,80.03,,31.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.73,90,,35.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.98,32.15,,12.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.98,32.15,,12.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.74,88,,34.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.46,33.11,,13.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.98,44.73,
MUMPS SKIN TEST,296038,CDM,250,RC,,,Outpatient,,,49.7,29.82,,42.25,85,,33.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.98,32.15,,12.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.77,80.03,,31.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.73,90,,35.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.98,32.15,,12.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.98,32.15,,12.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.74,88,,34.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.46,33.11,,13.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.98,44.73,
"FECAL FAT STAIN, QL OIL RED",1882705,CDM,300,RC,89125,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.43,44.78,
"HEMOSIDERIN, URINE  (MAYO)",1883070,CDM,300,RC,83070,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,44.78,
Urine test to measure albumin,1884232,CDM,300,RC,82043,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.28,44.78,
"SELENIUM, SERUM  (MAYO)",1884255,CDM,300,RC,84255,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,32.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.1,44.78,
URIC ACID CRYSTALS,1884555,CDM,300,RC,89060,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.47,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.47,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.99,44.78,
C1-ESTERASE INHIBITOR ASSAY  (MAYO),1886161,CDM,300,RC,86160,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,44.78,
Blood test to if peptic ulcers are caused by a certain bacterium,1886331,CDM,300,RC,86677,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.25,44.78,
".LYME DISEASE AB, SERUM, IGG  (MAYO)",1886618,CDM,300,RC,86617,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.48,44.78,
".LYME DISEASE AB, SERUM, IGM  (MAYO)",1886619,CDM,300,RC,86617,HCPCS,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.48,44.78,
"RUBEOLA AB,IGG & IGM, CSF  (MAYO)",1886765,CDM,300,RC,,,Outpatient,,,49.75,29.85,,42.29,85,,33.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.99,32.15,,12.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.81,80.03,,31.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.78,90,,35.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.99,32.15,,12.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.99,32.15,,12.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.78,88,,35.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.47,33.11,,13.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.99,44.78,
ANTI THYROID AB  (MAYO),1886591,CDM,300,RC,86800,HCPCS,Outpatient,,,49.86,29.92,,42.38,85,,33.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.9,80.03,,31.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.87,90,,35.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.88,88,,35.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20,44.87,
"Blood test, thyroid stimulating hormone (TSH)",1884443,CDM,300,RC,84443,HCPCS,Outpatient,,,49.91,29.95,,42.42,85,,33.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.94,80.03,,31.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,44.92,90,,35.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.92,88,,35.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.12,44.92,
THORAZINE CONC 30MG/ML : BOTTLE,292292,CDM,250,RC,,,Outpatient,,,49.96,29.98,,42.47,85,,33.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.06,32.15,,12.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.98,80.03,,31.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.96,90,,35.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.06,32.15,,12.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.06,32.15,,12.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.96,88,,35.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.54,33.11,,13.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.06,44.96,
BOARD BACK,49073,CDM,270,RC,,,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
SHEET IMPERVIOUS SPLIT 60  X 70,496152,CDM,270,RC,,,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
BLADE SURGICAL CLIPPER,499650,CDM,270,RC,,,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
SUPPORTER-LG ADULT,4997059,CDM,270,RC,,,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
SET ADMINISTRATION SPEC-SET,4998000,CDM,270,RC,,,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
GUIDEWIRE HYDROGLIDE STRT .025  145CM,4999044,CDM,272,RC,,,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
CARNITINE  (MAYO),1882379,CDM,300,RC,82379,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.21,45,
"HEPATITIS DELTA AB, ANTI-HDV  (MAYO)",1886692,CDM,300,RC,86692,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.58,45,
CYTOPATHOLOGY SMEAR PREP,2188161,CDM,310,RC,88333,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,40.02,75.49,
SUBQ INCENTIVE SPIROMETRY,30027,CDM,410,RC,94640,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
MDI TREATMENT,30240,CDM,410,RC,94640,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
RESP THER INSTRUCTION,30285,CDM,410,RC,,,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
DO NOT USE,311105,CDM,420,RC,97150,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.37,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17.37,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311108,CDM,420,RC,97110,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
HEARING SCREENING,28005,CDM,471,RC,92557,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
BACTRIM (sulfa/trimeth) IV INFUSION:10ML,293021,CDM,250,RC,S0039,HCPCS,Outpatient,,,50.22,30.13,,42.69,85,,34.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.19,80.03,,32.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.2,90,,36.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.19,88,,35.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.63,33.11,,13.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.15,45.2,
SILVADENE (SILVER SULFADIAZINE) 400GM,297049,CDM,250,RC,,,Outpatient,,,50.22,30.13,,42.69,85,,34.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.19,80.03,,32.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.2,90,,36.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.19,88,,35.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.63,33.11,,13.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.15,45.2,
P.A.C. SOLN (PONTO/ADREN/COCAINE) 5ML,299090,CDM,250,RC,,,Outpatient,,,50.22,30.13,,42.69,85,,34.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.19,80.03,,32.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.2,90,,36.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.19,88,,35.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.63,33.11,,13.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.15,45.2,
DELFLEX 1.5% : 2000ml PERITONEAL,296700,CDM,258,RC,,,Outpatient,,,50.22,30.13,,42.69,85,,34.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.19,80.03,,32.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.2,90,,36.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.15,32.15,,12.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.19,88,,35.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.63,33.11,,13.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.15,45.2,
PROBE TEMPERATURA RECTAL/ESOPHAGEAL,49011,CDM,270,RC,,,Outpatient,,,50.25,30.15,,42.71,85,,34.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.16,32.15,,12.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.22,80.03,,32.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.23,90,,36.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.16,32.15,,12.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.16,32.15,,12.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.22,88,,35.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.64,33.11,,13.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.16,45.23,
WICK EAR 16MM,4970523,CDM,270,RC,,,Outpatient,,,50.25,30.15,,42.71,85,,34.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.16,32.15,,12.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.22,80.03,,32.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.23,90,,36.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.16,32.15,,12.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.16,32.15,,12.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.22,88,,35.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.64,33.11,,13.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.16,45.23,
"B CELLS, TOTAL COUNT  (MAYO)",1886064,CDM,310,RC,86355,HCPCS,Outpatient,,,50.25,30.15,,42.71,85,,34.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.22,80.03,,32.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,38.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.23,90,,36.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.22,88,,35.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,29.62,45.23,
"NATURAL KILLER CELL SUBSETS, QUAN (MAYO)",1886351,CDM,310,RC,86357,HCPCS,Outpatient,,,50.25,30.15,,42.71,85,,34.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.22,80.03,,32.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,38.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.23,90,,36.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.22,88,,35.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,29.62,45.23,
NS W/ PITOCIN  20UNITS :1000ML,296298,CDM,636,RC,J2590,HCPCS,Outpatient,,,50.33,30.2,,42.78,85,,34.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.18,32.15,,12.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.28,80.03,,32.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.3,90,,36.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.18,32.15,,12.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.18,32.15,,12.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.29,88,,35.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.66,33.11,,13.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.18,45.3,
ERY PED (erythylsuc) 400MG/5ML SUSP100,295186,CDM,250,RC,,,Outpatient,,,50.42,30.25,,42.86,85,,34.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.21,32.15,,12.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.35,80.03,,32.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.38,90,,36.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.21,32.15,,12.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.21,32.15,,12.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.37,88,,35.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,33.11,,13.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.21,45.38,
DURAGESIC (fentanyl) 75mcg PATCH,292033,CDM,250,RC,,,Outpatient,,,50.47,30.28,,42.9,85,,34.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.23,32.15,,12.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.39,80.03,,32.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.42,90,,36.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.23,32.15,,12.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.23,32.15,,12.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.41,88,,35.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.71,33.11,,13.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.23,45.42,
DRESSING AQUACEL 4 X 4,491530,CDM,270,RC,,,Outpatient,,,50.5,30.3,,42.93,85,,34.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.24,32.15,,12.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.42,80.03,,32.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.45,90,,36.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.24,32.15,,12.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.24,32.15,,12.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.44,88,,35.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.72,33.11,,13.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.24,45.45,
HEMOSTAT CURVED MOSQUITO 4 3/4 DISP,4910086,CDM,270,RC,,,Outpatient,,,50.5,30.3,,42.93,85,,34.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.24,32.15,,12.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.42,80.03,,32.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.45,90,,36.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.24,32.15,,12.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.24,32.15,,12.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.44,88,,35.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.72,33.11,,13.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.24,45.45,
DRESSING TRANSPARENT 4X5  STERILE,49116,CDM,270,RC,,,Outpatient,,,50.63,30.38,,43.04,85,,34.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,32.15,,13.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.52,80.03,,32.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.57,90,,36.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,32.15,,13.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.28,32.15,,13.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.55,88,,35.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.76,33.11,,13.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.28,45.57,
NICORETTE (NICOTINE) 2MG BOX,29841,CDM,250,RC,,,Outpatient,,,50.73,30.44,,43.12,85,,34.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.31,32.15,,13.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.6,80.03,,32.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.66,90,,36.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.31,32.15,,13.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.31,32.15,,13.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.64,88,,35.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.8,33.11,,13.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.31,45.66,
PATTIES 1 X 3 NEURO SURGICAL,493075,CDM,270,RC,,,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.32,32.15,,13.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.32,32.15,,13.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.32,32.15,,13.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.8,33.11,,13.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.32,45.68,
"TOPIRAMATE, TOPAMAX  (MAYO)",1880201,CDM,300,RC,80201,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.99,45.68,
"N-TELEPEPTIDE, URINE  (MAYO)",1882523,CDM,300,RC,82523,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.05,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.05,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.5,45.68,
"THYROGLOBULIN AB, QT  (MAYO)",1886801,CDM,300,RC,86800,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20,45.68,
THYROGLOBULIN TUMOR REFLEX TO MS OR IA,1886803,CDM,300,RC,86800,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20,45.68,
Test of body fluid other than blood to assess for bacteria,1887061,CDM,300,RC,87070,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,45.68,
Test of body fluid other than blood to assess for bacteria,1887077,CDM,300,RC,87070,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,45.68,
Test of body fluid other than blood to assess for bacteria,1887078,CDM,300,RC,87070,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,45.68,
MALARIA SMEAR  (MAYO),1887207,CDM,300,RC,87207,HCPCS,Outpatient,,,50.75,30.45,,43.14,85,,34.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.62,80.03,,32.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.68,90,,36.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.66,88,,35.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.53,45.68,
HEMOSTAT STRAIGHT MOSQUITO 4 3/4 DISP,4910083,CDM,270,RC,,,Outpatient,,,51,30.6,,43.35,85,,34.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.4,32.15,,13.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.82,80.03,,32.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.9,90,,36.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.4,32.15,,13.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.4,32.15,,13.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.88,88,,35.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.89,33.11,,13.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.4,45.9,
CSF MYELIN BASIC PROTEIN   MAYO,1882043,CDM,300,RC,83873,HCPCS,Outpatient,,,51,30.6,,43.35,85,,34.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.82,80.03,,32.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.54,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.9,90,,36.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.54,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.88,88,,35.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.64,45.9,
"LIPASE, BODY FLUID  (MAYO)",1882980,CDM,300,RC,83690,HCPCS,Outpatient,,,51,30.6,,43.35,85,,34.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.82,80.03,,32.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,45.9,90,,36.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.88,88,,35.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.66,45.9,
CLEOCIN (clindamycin): 600MG VIAL,293353,CDM,250,RC,S0077,HCPCS,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.97,33.11,,13.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.48,46.13,
CHEMSTRIPS (SURE-STEP) BOX,292134,CDM,270,RC,,,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.97,33.11,,13.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.48,46.13,
TUBE ENDOTRACHEAL 3.5 N/C,493701,CDM,270,RC,,,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.97,33.11,,13.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.48,46.13,
APPLICATOR FLEXITIP ARISTA,4910080,CDM,270,RC,,,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.97,33.11,,13.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.48,46.13,
"HOMOVANILIC ACID, URINE  (MAYO)",1883150,CDM,300,RC,83150,HCPCS,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.34,46.13,
PORPHOBILINOGEN QT  (MAYO),1884121,CDM,300,RC,84110,HCPCS,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.62,46.13,
T3 REVERSE  (MAYO),1884486,CDM,300,RC,84482,HCPCS,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.07,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.07,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.82,46.13,
PENICILLIN : 20 MILL. UNITS PB,293136,CDM,636,RC,J2510,HCPCS,Outpatient,,,51.25,30.75,,43.56,85,,34.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.02,80.03,,32.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,46.13,90,,36.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,16.48,32.15,,13.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.1,88,,36.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.97,33.11,,13.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.48,46.13,
ACULAR (ketorolac) 0.5% OPTH: U/D,303954,CDM,250,RC,,,Outpatient,,,51.3,30.78,,43.61,85,,34.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.49,32.15,,13.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.06,80.03,,32.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.17,90,,36.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.49,32.15,,13.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.49,32.15,,13.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.14,88,,36.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.99,33.11,,13.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.49,46.17,
LOVENOX (enoxaparin) : 40MG INJ,293433,CDM,250,RC,,,Outpatient,,,51.35,30.81,,43.65,85,,34.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.1,80.03,,32.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.22,90,,36.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.19,88,,36.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17,33.11,,13.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.51,46.22,
NIZORAL (KETOCONAZOLE) CREAM 30GM,297095,CDM,250,RC,,,Outpatient,,,51.35,30.81,,43.65,85,,34.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.1,80.03,,32.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.22,90,,36.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.19,88,,36.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17,33.11,,13.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.51,46.22,
CALCIUM GLUCONATE 1GM /NS 100ML PB,293048,CDM,636,RC,J0610,HCPCS,Outpatient,,,51.35,30.81,,43.65,85,,34.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.1,80.03,,32.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.22,90,,36.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.51,32.15,,13.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.19,88,,36.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17,33.11,,13.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.51,46.22,
TUBE ENDOTRACHEAL 6.5,493734,CDM,270,RC,,,Outpatient,,,51.5,30.9,,43.78,85,,35.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.56,32.15,,13.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.22,80.03,,32.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.35,90,,37.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.56,32.15,,13.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.56,32.15,,13.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.32,88,,36.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.05,33.11,,13.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.56,46.35,
PRIMACOR (milrinone) 20MG/100ML D5W DRIP,293542,CDM,636,RC,J2260,HCPCS,Outpatient,,,51.5,30.9,,43.78,85,,35.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.22,80.03,,32.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.35,90,,37.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.32,88,,36.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.77,46.35,
Blood test to screen for bacteria in the blood,1887040,CDM,300,RC,87040,HCPCS,Outpatient,,,51.66,31,,43.91,85,,35.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.34,80.03,,33.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.49,90,,37.19,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.46,88,,36.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,46.49,
Blood test to screen for bacteria in the blood,1887041,CDM,300,RC,87040,HCPCS,Outpatient,,,51.66,31,,43.91,85,,35.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.34,80.03,,33.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.49,90,,37.19,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.46,88,,36.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,46.49,
OMNIPAQUE 350MG/ML 150ML VIAL,300418,CDM,250,RC,Q9967,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
IV THERAPY NEW DRUG CONCURRENT,1496368,CDM,260,RC,96368,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
CT NEEDLE 20-15 FRANSEEN LUNG BX,26078,CDM,270,RC,,,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
CT NEEDLE 20-20 FRANSEEN LUNG BX,26079,CDM,270,RC,,,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
CT NEEDLE 22-15 FRANSEEN LUNG BX,26080,CDM,270,RC,,,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
CT NEEDLE 18-15 FRANSEEN LUNG BX,26081,CDM,270,RC,,,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
CT NEEDLE 20-10 FRANSEEN LUNG BX,26082,CDM,270,RC,,,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
CATH MALE EXTERNAL STANDARD/LARGE,49417,CDM,270,RC,,,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
ALCOHOL BREATH,1882075,CDM,300,RC,82075,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
"PORPHYRINS, URINE QT RANDOM (MAYO)",1884120,CDM,300,RC,84110,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.62,46.58,
..BODY FLUID PROTEIN,1884156,CDM,300,RC,84155,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.61,46.58,
THEOPHYLLINE,1884420,CDM,300,RC,80198,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.79,46.58,
"Blood test, thyroid stimulating hormone (TSH)",1886810,CDM,300,RC,84443,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.12,46.58,
Form of decompression therapy of the spine,323,CDM,420,RC,97012,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
Form of decompression therapy of the spine,3197012,CDM,420,RC,97012,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
CORTONE (CORTISONE) 50MG/ML : 10ML INJ,293049,CDM,250,RC,,,Outpatient,,,51.76,31.06,,44,85,,35.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.55,88,,36.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.14,33.11,,13.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
PCA DILAUDID (hydromorphone)0.1MG/ML 60M,299067,CDM,250,RC,,,Outpatient,,,51.76,31.06,,44,85,,35.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.55,88,,36.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.14,33.11,,13.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
Flu shot-high dose for 2019-2020 flu season given by injection,293587,CDM,636,RC,90656,HCPCS,Outpatient,,,51.84,31.1,,44.06,85,,35.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.49,80.03,,33.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.66,90,,37.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,88,,36.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.16,33.11,,13.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.67,46.66,
DIGIFLEX EXERCISER,412,CDM,270,RC,,,Outpatient,,,51.85,31.11,,44.07,85,,35.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.5,80.03,,33.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,90,,37.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.63,88,,36.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.17,33.11,,13.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.67,46.67,
SPORTS CORD AND ACCESSORIES,31122,CDM,270,RC,,,Outpatient,,,51.85,31.11,,44.07,85,,35.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.5,80.03,,33.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,90,,37.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.63,88,,36.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.17,33.11,,13.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.67,46.67,
DRESSING COMBIDERM WOUND NON-ADHESIVE,491525,CDM,270,RC,,,Outpatient,,,51.85,31.11,,44.07,85,,35.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.5,80.03,,33.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,90,,37.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.67,32.15,,13.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.63,88,,36.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.17,33.11,,13.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.67,46.67,
Blood test to determine if antibodies exist for measles,1886319,CDM,300,RC,86765,HCPCS,Outpatient,,,51.88,31.13,,44.1,85,,35.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.52,80.03,,33.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.69,90,,37.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.65,88,,36.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,46.69,
"MANGANESE, SERUM  (MAYO)",1884250,CDM,300,RC,83785,HCPCS,Outpatient,,,52,31.2,,44.2,85,,35.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.62,80.03,,33.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,46.8,90,,37.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.76,88,,36.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.92,46.8,
CATH ULTRAMER 8FR URETHRAL RED RUBBER,49600,CDM,270,RC,,,Outpatient,,,52.25,31.35,,44.41,85,,35.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.8,32.15,,13.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.82,80.03,,33.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.03,90,,37.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.8,32.15,,13.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.8,32.15,,13.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.98,88,,36.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.3,33.11,,13.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.8,47.03,
HOME TRACTION UNIT,314014,CDM,270,RC,,,Outpatient,,,52.5,31.5,,44.63,85,,35.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.88,32.15,,13.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.02,80.03,,33.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.25,90,,37.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.88,32.15,,13.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.88,32.15,,13.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.2,88,,36.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.38,33.11,,13.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.88,47.25,
DELFLEX 2.5% : 2000ML PERITONEAL,296701,CDM,258,RC,,,Outpatient,,,52.53,31.52,,44.65,85,,35.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.89,32.15,,13.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.04,80.03,,33.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.28,90,,37.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.89,32.15,,13.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.89,32.15,,13.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.23,88,,36.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.39,33.11,,13.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.89,47.28,
PT E-VISIT 11-20 MIN,312062,CDM,420,RC,G2062,HCPCS,Outpatient,,,52.7,31.62,,44.8,85,,35.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.94,32.15,,13.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.18,80.03,,33.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.43,90,,37.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.94,32.15,,13.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.94,32.15,,13.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.38,88,,37.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.45,33.11,,13.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.94,47.43,
"OT E-VISIT, 11-20 MIN",592062,CDM,420,RC,G2062,HCPCS,Outpatient,,,52.7,31.62,,44.8,85,,35.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.94,32.15,,13.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.18,80.03,,33.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.43,90,,37.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.94,32.15,,13.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.94,32.15,,13.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.38,88,,37.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.45,33.11,,13.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.94,47.43,
Medical test to find an infection,1886259,CDM,300,RC,87081,HCPCS,Outpatient,,,52.75,31.65,,44.84,85,,35.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.22,80.03,,33.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,47.48,90,,37.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.42,88,,37.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.33,47.48,
Blood test to if peptic ulcers are caused by a certain bacterium,1886689,CDM,300,RC,86677,HCPCS,Outpatient,,,52.75,31.65,,44.84,85,,35.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.22,80.03,,33.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,47.48,90,,37.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.42,88,,37.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.25,47.48,
ZITHROMAX(azithromycin) 500MG/NS 250MLPB,293422,CDM,636,RC,J0456,HCPCS,Outpatient,,,52.83,31.7,,44.91,85,,35.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.98,32.15,,13.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.28,80.03,,33.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.55,90,,38.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.98,32.15,,13.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,16.98,32.15,,13.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.49,88,,37.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.49,33.11,,13.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.98,47.55,
OCUFLOX (OFLOXACIN) 0.3% OPTH 5ML,293424,CDM,250,RC,,,Outpatient,,,52.89,31.73,,44.96,85,,35.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17,32.15,,13.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.33,80.03,,33.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.6,90,,38.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17,32.15,,13.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17,32.15,,13.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.54,88,,37.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.51,33.11,,14.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17,47.6,
BANDAGE ACE 4,49125,CDM,270,RC,,,Outpatient,,,52.95,31.77,,45.01,85,,36.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.02,32.15,,13.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.38,80.03,,33.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.66,90,,38.13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.02,32.15,,13.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.02,32.15,,13.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.6,88,,37.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.53,33.11,,14.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.02,47.66,
CEFZIL (cefprozil) 125MG/5ML SUSP: 50ML,29083,CDM,250,RC,,,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
GENTAMICIN 100MG / NS 25ML PB,296237,CDM,250,RC,J1580,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,47.7,
OPIUM TINC. (DILUTED TO 0.4MG/ML CONC),299042,CDM,250,RC,,,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
SPECULA VAGINAL LARGE DISPOSABLE,49056,CDM,270,RC,,,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
NS W/ MVI/ THIAMINE & FOLVITE 1000ML,293233,CDM,272,RC,A4216,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
D-DIMER DO NOT USE YET!!!!!!,1885202,CDM,300,RC,85380,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.8,47.7,
GENTAMICIN 80MG VIAL,293359,CDM,636,RC,J1580,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,47.7,
OP OBSERVATION STEP-DOWN,15004,CDM,762,RC,99218,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53,,,,Other,Not Separately reimbursable,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
MONISTAT DUAL-PAK (MICONAZOLE),292023,CDM,250,RC,,,Outpatient,,,53.05,31.83,,45.09,85,,36.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.06,32.15,,13.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.46,80.03,,33.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.75,90,,38.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.06,32.15,,13.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.05,,,,Other,Not Separately reimbursable,17.06,32.15,,13.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.68,88,,37.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.56,33.11,,14.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.06,47.75,
VANCOCIN (vancomycin)  125MG CAP,29614,CDM,250,RC,,,Outpatient,,,53.2,31.92,,45.22,85,,36.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.1,32.15,,13.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.58,80.03,,34.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.88,90,,38.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.1,32.15,,13.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.2,,,,Other,Not Separately reimbursable,17.1,32.15,,13.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.82,88,,37.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.61,33.11,,14.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.1,47.88,
PSEUDOCHOLINESTERASE  (MAYO),1882480,CDM,300,RC,82480,HCPCS,Outpatient,,,53.25,31.95,,45.26,85,,36.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.62,80.03,,34.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,47.93,90,,38.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.86,88,,37.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.91,47.93,
CHROMASOME KAROTYPE,2188280,CDM,300,RC,88280,HCPCS,Outpatient,,,53.25,31.95,,45.26,85,,36.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.62,80.03,,34.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,34.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,47.93,90,,38.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.86,88,,37.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.56,47.93,
"CYTOGENETICS KAROTYPE, ADDL   (CSI)",2188281,CDM,300,RC,88280,HCPCS,Outpatient,,,53.25,31.95,,45.26,85,,36.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.62,80.03,,34.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,34.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,47.93,90,,38.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.86,88,,37.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.56,47.93,
KEPPRA (levetiracetam) 500MG /100ML NS,293196,CDM,636,RC,J1953,HCPCS,Outpatient,,,53.28,31.97,,45.29,85,,36.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.13,32.15,,13.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.64,80.03,,34.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.95,90,,38.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.13,32.15,,13.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.28,,,,Other,Not Separately reimbursable,17.13,32.15,,13.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.89,88,,37.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.64,33.11,,14.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.13,47.95,
DIFLUCAN  (fluconazole) 100MG /50ML PB,293851,CDM,636,RC,J1450,HCPCS,Outpatient,,,53.3,31.98,,45.31,85,,36.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.66,80.03,,34.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.97,90,,38.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.3,,,,Other,Not Separately reimbursable,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.9,88,,37.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.31,47.97,
MIOSTAT OPTH SOLN 1.5ML,297720,CDM,250,RC,,,Outpatient,,,53.31,31.99,,45.31,85,,36.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.14,32.15,,13.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.66,80.03,,34.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.98,90,,38.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.14,32.15,,13.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.31,,,,Other,Not Separately reimbursable,17.14,32.15,,13.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.91,88,,37.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.65,33.11,,14.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.14,47.98,
MEFOXIN (cefoxitin)  1GM /NS 50ML PB,293109,CDM,636,RC,J0694,HCPCS,Outpatient,,,53.38,32.03,,45.37,85,,36.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.72,80.03,,34.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.04,90,,38.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.38,,,,Other,Not Separately reimbursable,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.97,88,,37.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.17,48.04,
SLING ARM MEDIUM,491214,CDM,270,RC,,,Outpatient,,,53.44,32.06,,45.42,85,,36.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.77,80.03,,34.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.1,90,,38.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.44,,,,Other,Not Separately reimbursable,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.03,88,,37.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.69,33.11,,14.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.18,48.1,
STOPCOCK FOURWAY,493286,CDM,270,RC,,,Outpatient,,,53.44,32.06,,45.42,85,,36.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.77,80.03,,34.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.1,90,,38.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.44,,,,Other,Not Separately reimbursable,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.03,88,,37.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.69,33.11,,14.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.18,48.1,
DRAPE LARGE SHEET 53  X 77,499121,CDM,270,RC,,,Outpatient,,,53.44,32.06,,45.42,85,,36.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.77,80.03,,34.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.1,90,,38.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.44,,,,Other,Not Separately reimbursable,17.18,32.15,,13.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.03,88,,37.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.69,33.11,,14.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.18,48.1,
PEP THERAPY,30341,CDM,270,RC,,,Outpatient,,,53.5,32.1,,45.48,85,,36.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.82,80.03,,34.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.15,90,,38.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.5,,,,Other,Not Separately reimbursable,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.08,88,,37.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.71,33.11,,14.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.2,48.15,
SLING ARM X-LARGE,491209,CDM,270,RC,,,Outpatient,,,53.5,32.1,,45.48,85,,36.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.82,80.03,,34.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.15,90,,38.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.5,,,,Other,Not Separately reimbursable,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.08,88,,37.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.71,33.11,,14.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.2,48.15,
TUBE SALEM SUMP 18FR,493833,CDM,270,RC,,,Outpatient,,,53.51,32.11,,45.48,85,,36.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.82,80.03,,34.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.16,90,,38.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.51,,,,Other,Not Separately reimbursable,17.2,32.15,,13.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.09,88,,37.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.72,33.11,,14.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.2,48.16,
Test to determine level of iron in the blood,1882728,CDM,300,RC,82728,HCPCS,Outpatient,,,53.51,32.11,,45.48,85,,36.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.82,80.03,,34.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.16,90,,38.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.09,88,,37.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.13,48.16,
Prostate cancer screening; prostate specific antigen test (psa),1886137,CDM,300,RC,G0103,HCPCS,Outpatient,,,53.51,32.11,,45.48,85,,36.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.82,80.03,,34.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.16,90,,38.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.09,88,,37.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.7,48.16,
Blood test to screen for bacteria in the blood,1887042,CDM,300,RC,87040,HCPCS,Outpatient,,,53.51,32.11,,45.48,85,,36.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.82,80.03,,34.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.16,90,,38.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.09,88,,37.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,48.16,
PENICILLIN 10MU / NS  250 PB,293135,CDM,636,RC,J2510,HCPCS,Outpatient,,,53.53,32.12,,45.5,85,,36.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.84,80.03,,34.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,48.18,90,,38.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.11,88,,37.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.72,33.11,,14.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.21,48.18,
PENICILLIN 2MU/SW 40ML PB,293320,CDM,636,RC,J2510,HCPCS,Outpatient,,,53.53,32.12,,45.5,85,,36.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.84,80.03,,34.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,48.18,90,,38.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.11,88,,37.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.72,33.11,,14.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.21,48.18,
SENSOR NELLCOR NEO/ADULT OXISENSOR,49805,CDM,270,RC,,,Outpatient,,,53.54,32.12,,45.51,85,,36.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.85,80.03,,34.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.19,90,,38.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.21,32.15,,13.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.12,88,,37.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.73,33.11,,14.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.21,48.19,
TERAZOL 7 (terconazole) VAG CREAM,292021,CDM,250,RC,,,Outpatient,,,53.56,32.14,,45.53,85,,36.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.22,32.15,,13.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.86,80.03,,34.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.2,90,,38.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.22,32.15,,13.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.22,32.15,,13.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.13,88,,37.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.73,33.11,,14.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.22,48.2,
INP 4.25%: 2000ML,296702,CDM,258,RC,,,Outpatient,,,53.56,32.14,,45.53,85,,36.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.22,32.15,,13.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.86,80.03,,34.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.2,90,,38.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.22,32.15,,13.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.22,32.15,,13.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.13,88,,37.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.73,33.11,,14.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.22,48.2,
Blood test to diagnose mononucleosis,1886667,CDM,300,RC,86665,HCPCS,Outpatient,,,53.6,32.16,,45.56,85,,36.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.9,80.03,,34.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.24,90,,38.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.17,88,,37.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.82,48.24,
THIAMINE 200MG/100ML NS,302658,CDM,636,RC,J3411,HCPCS,Outpatient,,,53.66,32.2,,45.61,85,,36.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.25,32.15,,13.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.94,80.03,,34.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.29,90,,38.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.25,32.15,,13.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.25,32.15,,13.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.22,88,,37.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.77,33.11,,14.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.25,48.29,
STAINLESS SHOE HORN,405,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
CURVED SPOON,411,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
ELASTOMER,423,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
McKenzie Roll,430,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
NUTRITIONAL SUPPORT PROGRAM,49032,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
JACKET STRAIT,49075,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
POST/NASAL/HEMOR/TRAY ER,49215,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
KIT SPECI-CATH NEONATAL 5FR,49554,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
TRAY MANOMETER,492056,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
PATTIES 1/2 X 1 NEURO SURGICAL,493074,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
SPONGE TONSIL MEDIUM SINGLE STERILE,493081,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
SLEEVE SUR-FIT IRRIGATION 1 3/4,493210,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
SLEEVE IRRIGATION 4,493211,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
WAFFER STOMAHESIVE FLANGE 4,493227,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
POUCH UROSTOMY 1-3/4  NATURA SUR-FIT,493232,CDM,270,RC,,,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
COLLAR EXTRACTION CERVICAL,49024,CDM,274,RC,L0120,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
Basic metabolic panel,1880008,CDM,300,RC,80048,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.65,48.38,
"HOMOCYSTEINE,SERUM  (MAYO)",1882133,CDM,300,RC,83090,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.21,48.38,
"CORTISOL, URINE 24 HR (MAYO)",1882532,CDM,300,RC,82530,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.02,48.38,
"FECAL FAT, QT  (MAYO)",1882706,CDM,300,RC,82710,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.12,48.38,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1883522,CDM,300,RC,83516,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,48.38,
"METANEPHRINES FRACT 24 HR, URINE  (MAYO)",1883835,CDM,300,RC,83835,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.3,48.38,
METANEPHRINES FRACT.  PLASMA  (MAYO),1883836,CDM,300,RC,83835,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.3,48.38,
T3 FREE  (MAYO),1884482,CDM,300,RC,84481,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.3,48.38,
"Complete blood cell count, with differential white blood cells, automated",1885023,CDM,300,RC,85025,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.92,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.92,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.77,48.38,
SPECIAL COAG INTERPRETATION  (MAYO),1885203,CDM,300,RC,85390,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.5,48.38,
"ALPHA FETOPROTEIN, TUMOR MARKER  (MAYO)",1886246,CDM,300,RC,82105,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.1,48.38,
".WEST NILE VIRUS, IGM  (MAYO)",1886794,CDM,300,RC,86788,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.19,48.38,
Repeated application to one or more parts of the body,3110016,CDM,420,RC,97032,HCPCS,Outpatient,,,53.75,32.25,,45.69,85,,36.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.02,80.03,,34.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,48.38,90,,38.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,17.28,32.15,,13.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.3,88,,37.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.8,33.11,,14.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.28,48.38,
SET BURETTE PUMP 60 DROP,492152,CDM,270,RC,,,Outpatient,,,53.92,32.35,,45.83,85,,36.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.34,32.15,,13.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.15,80.03,,34.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.53,90,,38.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.34,32.15,,13.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.34,32.15,,13.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.45,88,,37.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.85,33.11,,14.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.34,48.53,
BANDAGE SELF ADHRNT 2 X 5YD CO-FLEX STRL,49117,CDM,270,RC,,,Outpatient,,,54,32.4,,45.9,85,,36.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.22,80.03,,34.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.6,90,,38.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.52,88,,38.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.88,33.11,,14.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.36,48.6,
ORTHO-DIESTROL (DIENESTROL) VAG CREAM,292014,CDM,250,RC,,,Outpatient,,,54.08,32.45,,45.97,85,,36.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.39,32.15,,13.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.28,80.03,,34.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.67,90,,38.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.39,32.15,,13.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.39,32.15,,13.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.59,88,,38.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.91,33.11,,14.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.39,48.67,
LR IRRIG  2000ML,296255,CDM,258,RC,,,Outpatient,,,54.08,32.45,,45.97,85,,36.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.39,32.15,,13.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.28,80.03,,34.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.67,90,,38.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.39,32.15,,13.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.39,32.15,,13.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.59,88,,38.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.91,33.11,,14.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.39,48.67,
FORTAZ (ceftazidime) : 1GM VIAL,293356,CDM,636,RC,J0713,HCPCS,Outpatient,,,54.08,32.45,,45.97,85,,36.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.28,80.03,,34.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.67,90,,38.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.59,88,,38.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.78,48.67,
SET BLOOD Y-TYPE,492154,CDM,270,RC,,,Outpatient,,,54.12,32.47,,46,85,,36.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.4,32.15,,13.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.31,80.03,,34.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.71,90,,38.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.4,32.15,,13.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.4,32.15,,13.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.63,88,,38.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.92,33.11,,14.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.4,48.71,
HCG QUANTITATIVE,1884702,CDM,300,RC,84702,HCPCS,Outpatient,,,54.38,32.63,,46.22,85,,36.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.52,80.03,,34.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,48.94,90,,39.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.85,88,,38.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.31,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.07,48.94,
ANTI-GLOMERULAR BASEMENT  (MAYO),1886302,CDM,300,RC,83520,HCPCS,Outpatient,,,54.5,32.7,,46.33,85,,37.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.62,80.03,,34.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.05,90,,39.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.96,88,,38.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,49.05,
ER INJECTION FEE,14025,CDM,450,RC,99201,HCPCS,Outpatient,,,54.5,32.7,,46.33,85,,37.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.52,32.15,,14.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.62,80.03,,34.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.05,90,,39.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.52,32.15,,14.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.52,32.15,,14.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.96,88,,38.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.04,33.11,,14.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.52,49.05,
BRETYLOL ( BRETYLIUM ) 500MG VIAL,293027,CDM,250,RC,,,Outpatient,,,54.59,32.75,,46.4,85,,37.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,80.03,,34.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.13,90,,39.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.04,88,,38.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.07,33.11,,14.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.55,49.13,
CEFOTAN (CEFOTETAN) : 1GM PB,293311,CDM,250,RC,S0074,HCPCS,Outpatient,,,54.59,32.75,,46.4,85,,37.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,80.03,,34.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.13,90,,39.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.04,88,,38.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.07,33.11,,14.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.55,49.13,
TERAZOL-3 (terconazole) SUPPOSITORIES,296083,CDM,250,RC,,,Outpatient,,,54.59,32.75,,46.4,85,,37.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,80.03,,34.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.13,90,,39.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.04,88,,38.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.07,33.11,,14.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.55,49.13,
TOBREX (TOBRAMYCIN) OPTH OINT 3.5G,297770,CDM,250,RC,,,Outpatient,,,54.59,32.75,,46.4,85,,37.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,80.03,,34.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.13,90,,39.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.55,32.15,,14.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.04,88,,38.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.07,33.11,,14.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.55,49.13,
VANCOMYCIN 1.25GM /250ML PREMIXED IVPB,303885,CDM,636,RC,J3370,HCPCS,Outpatient,,,54.72,32.83,,46.51,85,,37.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.79,80.03,,35.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.25,90,,39.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.15,88,,38.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,49.25,
TUBE ENDOTRACHEAL 6.0,493728,CDM,270,RC,,,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.6,32.15,,14.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.6,32.15,,14.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.6,32.15,,14.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.13,33.11,,14.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.6,49.28,
DRESSING MAXORB II 4X4 ALGINATE,498024,CDM,270,RC,,,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.6,32.15,,14.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.6,32.15,,14.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.6,32.15,,14.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.13,33.11,,14.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.6,49.28,
"METHYLMALONIC ACID, MMA, SERUM  (MAYO)",1882132,CDM,300,RC,83921,HCPCS,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.7,49.28,
"METHYLMALONIC ACID, QN, SERUM  (MAYO)",1882134,CDM,300,RC,83921,HCPCS,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.7,49.28,
"PTH RELATED PEPTIDE, PTHRP  (MAYO)",1882397,CDM,300,RC,82397,HCPCS,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.77,49.28,
Test of hormone in the blood,1883000,CDM,300,RC,83001,HCPCS,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.37,49.28,
"BETA - HYDROXYBUTYRATE,  (MAYO)",1884312,CDM,300,RC,82010,HCPCS,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.28,49.28,
D-DIMER,1885379,CDM,300,RC,85380,HCPCS,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.8,49.28,
LYME DISEASE SEROLOGY  (MAYO),1886314,CDM,300,RC,86618,HCPCS,Outpatient,,,54.75,32.85,,46.54,85,,37.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.82,80.03,,35.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.37,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.28,90,,39.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.37,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.18,88,,38.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.42,49.28,
ELIMITE CREAM 5% 60GM,298031,CDM,250,RC,,,Outpatient,,,54.85,32.91,,46.62,85,,37.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.63,32.15,,14.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.9,80.03,,35.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.37,90,,39.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.63,32.15,,14.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.63,32.15,,14.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.27,88,,38.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.16,33.11,,14.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.63,49.37,
AEROBIKA  PEP DEVICE,30405,CDM,270,RC,,,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
CRUTCHES,31301,CDM,270,RC,,,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
DRESSING ALLEVYN 4 X 4,491531,CDM,270,RC,,,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1886850,CDM,300,RC,83516,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,49.5,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1886851,CDM,300,RC,83516,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,49.5,
BREAST SURGICAL SPECIMEN,22124,CDM,320,RC,76098,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.35,102,,,fee schedule,Pays at 102% of CMS APC rate,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.35,100,,,fee schedule,Pays at 100% of CMS APC rate,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
A technique used by physical therapists to restore normal body movement patterns,313024,CDM,430,RC,97112,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
A technique used by physical therapists to restore normal body movement patterns,313025,CDM,430,RC,97112,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
Therapy for speech or hearing,312007,CDM,440,RC,92507,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
DO NOT USE,3195904,CDM,922,RC,95900,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.68,32.15,,14.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.21,33.11,,14.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.68,49.5,
MONISTAT-7 (MICONAZOLE) VAG SUPP #7,292050,CDM,250,RC,,,Outpatient,,,55.11,33.07,,46.84,85,,37.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.1,80.03,,35.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.6,90,,39.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.5,88,,38.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.25,33.11,,14.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.72,49.6,
PROZAC (FLUOXETINE) 20MG/5ML SOLN: 1OZ,292322,CDM,250,RC,,,Outpatient,,,55.11,33.07,,46.84,85,,37.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.1,80.03,,35.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.6,90,,39.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.5,88,,38.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.25,33.11,,14.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.72,49.6,
CARDIZEM (diltiazem) : 50MG INJ,293115,CDM,250,RC,,,Outpatient,,,55.11,33.07,,46.84,85,,37.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.1,80.03,,35.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.6,90,,39.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.72,32.15,,14.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.5,88,,38.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.25,33.11,,14.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.72,49.6,
OXACILLIN : 1GM VIAL,293375,CDM,636,RC,J2700,HCPCS,Outpatient,,,55.11,33.07,,46.84,85,,37.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.1,80.03,,35.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.6,90,,39.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.5,88,,38.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.97,49.6,
"..CULTURE, CHLAMYDIA TRACH AMP  (MAYO)",1887110,CDM,300,RC,87110,HCPCS,Outpatient,,,55.19,33.11,,46.91,85,,37.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.17,80.03,,35.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.67,90,,39.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.57,88,,38.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.63,49.67,
CATHETER STRAP UNIVERSAL,49523,CDM,270,RC,,,Outpatient,,,55.5,33.3,,47.18,85,,37.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.42,80.03,,35.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.95,90,,39.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.84,88,,39.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.38,33.11,,14.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.84,49.95,
GLIDESCOPE STAT 4 GVL,4999980,CDM,270,RC,,,Outpatient,,,55.5,33.3,,47.18,85,,37.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.42,80.03,,35.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.95,90,,39.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.84,88,,39.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.38,33.11,,14.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.84,49.95,
Testing for presence of drug,1882778,CDM,300,RC,80307,HCPCS,Outpatient,,,55.5,33.3,,47.18,85,,37.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.42,80.03,,35.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.95,90,,39.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.84,88,,39.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.42,61.16,
"TRICYCLIC ANTIDEPRESSANTS, SERUM  (MAYO)",1882779,CDM,300,RC,80101,HCPCS,Outpatient,,,55.5,33.3,,47.18,85,,37.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.42,80.03,,35.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.95,90,,39.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.84,32.15,,14.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.84,88,,39.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.38,33.11,,14.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.84,49.95,
SEX HORMONE BINDING GLOB  (MAYO),1884406,CDM,300,RC,84270,HCPCS,Outpatient,,,55.5,33.3,,47.18,85,,37.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.42,80.03,,35.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.95,90,,39.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.84,88,,39.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.32,49.95,
RICKETTSIA SERUM ABS  (MAYO),1889054,CDM,300,RC,86757,HCPCS,Outpatient,,,55.5,33.3,,47.18,85,,37.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.42,80.03,,35.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,49.95,90,,39.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.84,88,,39.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,49.95,
AMPICILLIN 1GM/50ML NS PB,293131,CDM,636,RC,J0290,HCPCS,Outpatient,,,55.73,33.44,,47.37,85,,37.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.6,80.03,,35.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.16,90,,40.13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.04,88,,39.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,50.16,
STOCKING KNEE-HI MEDIUM LONG,493163,CDM,270,RC,,,Outpatient,,,55.75,33.45,,47.39,85,,37.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.62,80.03,,35.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.18,90,,40.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.06,88,,39.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.46,33.11,,14.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.92,50.18,
STOCKING KNEE-HI LARGE LONG,493164,CDM,270,RC,,,Outpatient,,,55.75,33.45,,47.39,85,,37.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.62,80.03,,35.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.18,90,,40.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.06,88,,39.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.46,33.11,,14.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.92,50.18,
STOCKING KNEE-HI X-LG LONG 17-1/2  - 20,493165,CDM,270,RC,,,Outpatient,,,55.75,33.45,,47.39,85,,37.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.62,80.03,,35.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.18,90,,40.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.06,88,,39.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.46,33.11,,14.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.92,50.18,
STOCKING KNEE-HI X-LG REG. 17-1/2  - 20,493166,CDM,270,RC,,,Outpatient,,,55.75,33.45,,47.39,85,,37.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.62,80.03,,35.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.18,90,,40.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.06,88,,39.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.46,33.11,,14.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.92,50.18,
STOCKING KNEE-HI SMALL REGULAR,493184,CDM,270,RC,,,Outpatient,,,55.75,33.45,,47.39,85,,37.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.62,80.03,,35.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.18,90,,40.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.06,88,,39.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.46,33.11,,14.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.92,50.18,
TUBE ENDOTRACHEAL 4.5,493710,CDM,270,RC,,,Outpatient,,,55.75,33.45,,47.39,85,,37.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.62,80.03,,35.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.18,90,,40.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.92,32.15,,14.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.06,88,,39.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.46,33.11,,14.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.92,50.18,
BRONKOMETER INHALER 10ML,292043,CDM,250,RC,,,Outpatient,,,55.88,33.53,,47.5,85,,38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.72,80.03,,35.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.29,90,,40.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.17,88,,39.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.5,33.11,,14.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.97,50.29,
RAPLON 100MG/ 5ML INJ,293506,CDM,250,RC,,,Outpatient,,,55.88,33.53,,47.5,85,,38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.72,80.03,,35.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.29,90,,40.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.17,88,,39.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.5,33.11,,14.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.97,50.29,
XYLOCAINE 10% ORAL SP,298054,CDM,250,RC,,,Outpatient,,,55.88,33.53,,47.5,85,,38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.72,80.03,,35.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.29,90,,40.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.17,88,,39.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.5,33.11,,14.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.97,50.29,
D5W W/DOP 800MG: 500ML,296158,CDM,258,RC,,,Outpatient,,,55.88,33.53,,47.5,85,,38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.72,80.03,,35.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.29,90,,40.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.97,32.15,,14.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.17,88,,39.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.5,33.11,,14.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.97,50.29,
ZOSYN 4.5GM VIAL - RX COMPOUND,300649,CDM,250,RC,,,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.54,33.11,,14.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18,50.4,
TUBE ENDOTRACHEAL 4.0,493704,CDM,270,RC,,,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.54,33.11,,14.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18,50.4,
TUBE ENDOTRACHEAL 5.0,493716,CDM,270,RC,,,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.54,33.11,,14.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18,50.4,
GABAPENTIN (NEURONTIN) URINE  (MAYO),1880299,CDM,300,RC,80171,HCPCS,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.47,50.4,
"SULFATE, 24HR URINE  (MAYO)",1882198,CDM,300,RC,84392,HCPCS,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,50.4,
PROTEIN C AG  (MAYO),1885303,CDM,300,RC,85302,HCPCS,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.12,50.4,
"EBNA AB, SERUM  (MAYO)",1886670,CDM,300,RC,86664,HCPCS,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.24,50.4,
KIT WOUND DRAIN 7FR 3/32  400CC,4900401,CDM,270,RC,,,Outpatient,,,56.1,33.66,,47.69,85,,38.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.04,32.15,,14.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.9,80.03,,35.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.49,90,,40.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.04,32.15,,14.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.04,32.15,,14.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.37,88,,39.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.57,33.11,,14.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.04,50.49,
ANDROSTENDIONE  (MAYO),1882157,CDM,300,RC,82157,HCPCS,Outpatient,,,56.25,33.75,,47.81,85,,38.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.02,80.03,,36.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,29.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.63,90,,40.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,36.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.5,88,,39.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.81,50.63,
IgF-BP3  (MAYO),1883518,CDM,300,RC,83519,HCPCS,Outpatient,,,56.25,33.75,,47.81,85,,38.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.02,80.03,,36.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.63,90,,40.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.5,88,,39.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,50.63,
BSS 500ML,292001,CDM,250,RC,,,Outpatient,,,56.4,33.84,,47.94,85,,38.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.13,32.15,,14.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.14,80.03,,36.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.76,90,,40.61,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.13,32.15,,14.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.13,32.15,,14.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.63,88,,39.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.67,33.11,,14.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.13,50.76,
TUBE ENDOTRACHEAL 5.5,493722,CDM,270,RC,,,Outpatient,,,56.5,33.9,,48.03,85,,38.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.16,32.15,,14.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.22,80.03,,36.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.85,90,,40.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.16,32.15,,14.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.16,32.15,,14.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.72,88,,39.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.71,33.11,,14.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.16,50.85,
"CATECHOLAMINE FREE, PLASMA(FRACTIONATED)",1882384,CDM,300,RC,82384,HCPCS,Outpatient,,,56.5,33.9,,48.03,85,,38.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.22,80.03,,36.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.85,90,,40.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.72,88,,39.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.75,50.85,
GRASS #2 ALLERGANS IGE  (MAYO),1886807,CDM,300,RC,86003,HCPCS,Outpatient,,,56.5,33.9,,48.03,85,,38.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.22,80.03,,36.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,50.85,90,,40.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.72,88,,39.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,50.85,
O/T FINGER/ORTHOTICS W/O JOINTS,362,CDM,274,RC,L3933,HCPCS,Outpatient,,,56.6,33.96,,48.11,85,,38.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.2,32.15,,14.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.3,80.03,,36.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.94,90,,40.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.2,32.15,,14.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.2,32.15,,14.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.81,88,,39.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.74,33.11,,14.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.2,50.94,
TUBE ENDOTRACHEAL 3.0,493698,CDM,270,RC,,,Outpatient,,,56.75,34.05,,48.24,85,,38.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.42,80.03,,36.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.08,90,,40.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.94,88,,39.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.79,33.11,,15.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.25,51.08,
TUBE ENDOTRACHEAL 7.0 UNCUFFED  ORAL RAE,493742,CDM,270,RC,,,Outpatient,,,56.75,34.05,,48.24,85,,38.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.42,80.03,,36.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.08,90,,40.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.94,88,,39.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.79,33.11,,15.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.25,51.08,
TUBE ENDOTRACHEAL 8.5,493758,CDM,270,RC,,,Outpatient,,,56.75,34.05,,48.24,85,,38.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.42,80.03,,36.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.08,90,,40.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.94,88,,39.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.79,33.11,,15.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.25,51.08,
TUBE ENDOTRACHEAL 9.0,493764,CDM,270,RC,,,Outpatient,,,56.75,34.05,,48.24,85,,38.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.42,80.03,,36.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.08,90,,40.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.94,88,,39.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.79,33.11,,15.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.25,51.08,
TUBE ENDOTRACHEAL 9.5,493770,CDM,270,RC,,,Outpatient,,,56.75,34.05,,48.24,85,,38.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.42,80.03,,36.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.08,90,,40.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.94,88,,39.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.79,33.11,,15.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.25,51.08,
TUBE ENDOTRACHEAL 10.0,493774,CDM,270,RC,,,Outpatient,,,56.75,34.05,,48.24,85,,38.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.42,80.03,,36.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.08,90,,40.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.25,32.15,,14.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.94,88,,39.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.79,33.11,,15.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.25,51.08,
AIRWAY CARE,30290,CDM,270,RC,,,Outpatient,,,56.79,34.07,,48.27,85,,38.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.26,32.15,,14.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.45,80.03,,36.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.11,90,,40.89,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.26,32.15,,14.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.26,32.15,,14.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.98,88,,39.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,33.11,,15.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.26,51.11,
Blood test to determine infection with Hepatitis C,1886294,CDM,300,RC,86803,HCPCS,Outpatient,,,56.88,34.13,,48.35,85,,38.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.52,80.03,,36.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.55,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.19,90,,40.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.55,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.05,88,,40.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10,51.19,
MISC DRUG 50,29907,CDM,250,RC,,,Outpatient,,,56.91,34.15,,48.37,85,,38.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.3,32.15,,14.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.55,80.03,,36.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.22,90,,40.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.3,32.15,,14.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.3,32.15,,14.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.08,88,,40.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.84,33.11,,15.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.3,51.22,
BUR BONE CUTTING LONG 5MM CARBIDE ROUND,49724,CDM,270,RC,,,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
VALVE LOPEZ,499999,CDM,270,RC,,,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
PSA (prostate specific antigen) measurement,1884154,CDM,300,RC,84154,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.13,51.3,
SMITH AUTOAB  (MAYO),1886232,CDM,300,RC,86235,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,51.3,
"ANTI-SSA, SJORGEN'S  (MAYO)",1886234,CDM,300,RC,86235,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,51.3,
"ANTI-SSB, SJORGEN'S  (MAYO)",1886236,CDM,300,RC,86235,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,51.3,
JO-1 AB  (MAYO),1886237,CDM,300,RC,86235,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,51.3,
"SCL-70 AB, IGG  (MAYO)",1886238,CDM,300,RC,86235,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,51.3,
RNP ANTIBODY  (MAYO),1886239,CDM,300,RC,86235,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,51.3,
ADENOCARD (adenosine) 6MG VIAL,293000,CDM,636,RC,J0153,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.54,51.3,
ADENOCARD (adenosine) 12MG/4ML VIAL,293183,CDM,636,RC,J0153,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.54,51.3,
GENTAMICIN 120MG / NS 30ML PB,296238,CDM,636,RC,J1580,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,51.3,
OXYTROL 3.9 MG/DAY PATCH,292139,CDM,250,RC,,,Outpatient,,,57.17,34.3,,48.59,85,,38.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.38,32.15,,14.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.75,80.03,,36.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.45,90,,41.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.38,32.15,,14.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.38,32.15,,14.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.31,88,,40.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.93,33.11,,15.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.38,51.45,
MEFOXIN (cefoxitin) : 2GM VIAL,293364,CDM,636,RC,J0694,HCPCS,Outpatient,,,57.4,34.44,,48.79,85,,39.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.94,80.03,,36.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.66,90,,41.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.51,88,,40.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.17,51.66,
"Diphtheria, tetanus acellular, and pertussis vaccine for adults",1490701,CDM,636,RC,90715,HCPCS,Outpatient,,,57.5,34.5,,48.88,85,,39.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.02,80.03,,36.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.75,90,,41.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,38.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.6,88,,40.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,38.67,51.75,
EPIFOAM (HC/pramoxine) 10 G,291058,CDM,250,RC,,,Outpatient,,,57.7,34.62,,49.05,85,,39.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.55,32.15,,14.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.18,80.03,,36.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.93,90,,41.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.55,32.15,,14.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.55,32.15,,14.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.78,88,,40.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.1,33.11,,15.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.55,51.93,
PAD TUCKS PERIES,491902,CDM,270,RC,,,Outpatient,,,57.75,34.65,,49.09,85,,39.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.57,32.15,,14.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.22,80.03,,36.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.98,90,,41.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.57,32.15,,14.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.57,32.15,,14.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,88,,40.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.12,33.11,,15.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.57,51.98,
FREEDOM THUMBKEEPER,431,CDM,270,RC,,,Outpatient,,,57.8,34.68,,49.13,85,,39.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.58,32.15,,14.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.26,80.03,,37.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.02,90,,41.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.58,32.15,,14.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.58,32.15,,14.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.86,88,,40.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.14,33.11,,15.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.58,52.02,
METROGEL (METRONID) VAGINAL 0.75% 70GM,297087,CDM,250,RC,,,Outpatient,,,57.94,34.76,,49.25,85,,39.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.63,32.15,,14.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.37,80.03,,37.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.15,90,,41.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.63,32.15,,14.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.63,32.15,,14.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.99,88,,40.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.18,33.11,,15.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.63,52.15,
METROGEL (METRONID) TOP 1 % GEL 45 GRAMS,297102,CDM,250,RC,,,Outpatient,,,57.94,34.76,,49.25,85,,39.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.63,32.15,,14.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.37,80.03,,37.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.15,90,,41.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.63,32.15,,14.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.63,32.15,,14.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.99,88,,40.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.18,33.11,,15.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.63,52.15,
CLAFORAN  (cefotaxime) 1GM /SW 10ML PB,293040,CDM,636,RC,J0698,HCPCS,Outpatient,,,57.94,34.76,,49.25,85,,39.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.37,80.03,,37.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.15,90,,41.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.99,88,,40.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.8,52.15,
"BODY FLUID, ALBUMIN  (MAYO)",1882962,CDM,300,RC,82042,HCPCS,Outpatient,,,58,34.8,,49.3,85,,39.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.42,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,52.2,90,,41.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.04,88,,40.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,52.2,
Blood test to diagnose mononucleosis,1886668,CDM,300,RC,86665,HCPCS,Outpatient,,,58,34.8,,49.3,85,,39.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.42,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,52.2,90,,41.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.04,88,,40.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.82,52.2,
Blood test to diagnose mononucleosis,1886669,CDM,300,RC,86665,HCPCS,Outpatient,,,58,34.8,,49.3,85,,39.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.42,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,52.2,90,,41.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.04,88,,40.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.82,52.2,
Test of body fluid other than blood to assess for bacteria,1887070,CDM,300,RC,87070,HCPCS,Outpatient,,,58,34.8,,49.3,85,,39.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.42,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,52.2,90,,41.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.04,88,,40.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,52.2,
PERIPHERAL REVIEW BY PATHOLOGIST,1885024,CDM,310,RC,85060,HCPCS,Outpatient,,,58,34.8,,49.3,85,,39.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.42,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.2,90,,41.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.04,88,,40.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.97,52.2,
TETRACAINE 0.5% O/S/U 2ML,297743,CDM,250,RC,,,Outpatient,,,58.02,34.81,,49.32,85,,39.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.43,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.22,90,,41.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.06,88,,40.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.21,33.11,,15.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.65,52.22,
TETRACAINE 0.5% SINGLE DOSE,297778,CDM,250,RC,,,Outpatient,,,58.02,34.81,,49.32,85,,39.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.43,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.22,90,,41.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.06,88,,40.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.21,33.11,,15.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.65,52.22,
PLAVIX (clopidogrel) 300MG TAB,291165,CDM,250,RC,,,Outpatient,,,58.4,35.04,,49.64,85,,39.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.78,32.15,,15.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.74,80.03,,37.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.56,90,,42.05,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.78,32.15,,15.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.78,32.15,,15.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.39,88,,41.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.34,33.11,,15.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.78,52.56,
XALATAN (latanoprost) 0.005% SOLN 2.5ML,293443,CDM,250,RC,,,Outpatient,,,58.5,35.1,,49.73,85,,39.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.81,32.15,,15.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.82,80.03,,37.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.65,90,,42.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.81,32.15,,15.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.81,32.15,,15.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.48,88,,41.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.37,33.11,,15.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.81,52.65,
CT NEEDLE 18-10 FRANSEEN LUNG BX,26083,CDM,270,RC,,,Outpatient,,,58.5,35.1,,49.73,85,,39.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.81,32.15,,15.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.82,80.03,,37.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.65,90,,42.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.81,32.15,,15.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.81,32.15,,15.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.48,88,,41.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.37,33.11,,15.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.81,52.65,
ASCORBIC ACID (MAYO),1882180,CDM,300,RC,82180,HCPCS,Outpatient,,,58.5,35.1,,49.73,85,,39.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,46.82,80.03,,37.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,52.65,90,,42.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.48,88,,41.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.11,52.65,
Blood test to measure level of prealbumin,1882042,CDM,300,RC,84134,HCPCS,Outpatient,,,58.74,35.24,,49.93,85,,39.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.01,80.03,,37.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.88,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,52.87,90,,42.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.88,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.69,88,,41.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.89,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.34,52.87,
VASOTEC (enalapril) 1.25MG/ML INJ,293403,CDM,250,RC,,,Outpatient,,,58.97,35.38,,50.12,85,,40.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.96,32.15,,15.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.19,80.03,,37.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.07,90,,42.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.96,32.15,,15.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.96,32.15,,15.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.89,88,,41.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,33.11,,15.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.96,53.07,
ELOCON 0.1% CREAM 45GM,297086,CDM,250,RC,,,Outpatient,,,58.97,35.38,,50.12,85,,40.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.96,32.15,,15.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.19,80.03,,37.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.07,90,,42.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.96,32.15,,15.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.96,32.15,,15.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.89,88,,41.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,33.11,,15.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.96,53.07,
WEANING MECHANICS,30015,CDM,270,RC,,,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.53,33.11,,15.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.97,53.1,
PROBE RECTAL 9FR,49010,CDM,270,RC,,,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.53,33.11,,15.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.97,53.1,
SET IRRIGATION TUBING BORE LG. SPIKE UNV,496479,CDM,270,RC,,,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.53,33.11,,15.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.97,53.1,
Test of hormone in the blood,1883001,CDM,300,RC,83001,HCPCS,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.37,53.1,
Test of hormone in the blood,1883002,CDM,300,RC,83002,HCPCS,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.29,53.1,
PSA (prostate specific antigen),1884153,CDM,300,RC,84153,HCPCS,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.13,53.1,
PROTEIN C ACTIVITY TOTAL & FREE (MAYO),1885308,CDM,300,RC,85303,HCPCS,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.11,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.11,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.39,53.1,
STRAPPING; ELBOW OR WRIST,1429260,CDM,450,RC,29260,HCPCS,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.53,33.11,,15.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.97,53.1,
STRAPPING; HAND OR FINGER,1429280,CDM,450,RC,29280,HCPCS,Outpatient,,,59,35.4,,50.15,85,,40.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.22,80.03,,37.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,53.1,90,,42.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,18.97,32.15,,15.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.92,88,,41.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.53,33.11,,15.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.97,53.1,
SET EXTENSION 2 CARESITES 35,492143,CDM,270,RC,,,Outpatient,,,59.06,35.44,,50.2,85,,40.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.99,32.15,,15.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.27,80.03,,37.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.15,90,,42.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.99,32.15,,15.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.06,,,,Other,Not Separately reimbursable,18.99,32.15,,15.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.97,88,,41.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.55,33.11,,15.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.99,53.15,
LAMISIL CREAM (terbinafine) 1%  15GM,298066,CDM,250,RC,,,Outpatient,,,59.07,35.44,,50.21,85,,40.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.99,32.15,,15.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.27,80.03,,37.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.16,90,,42.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.99,32.15,,15.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.07,,,,Other,Not Separately reimbursable,18.99,32.15,,15.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.98,88,,41.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.56,33.11,,15.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.99,53.16,
"E HISTOLYTICA AB, SERUM  (MAYO)",1886279,CDM,300,RC,86280,HCPCS,Outpatient,,,59.1,35.46,,50.24,85,,40.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.3,80.03,,37.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,53.19,90,,42.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.01,88,,41.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.3,53.19,
NITROGLYCERIN 50MG/250ML DRIP,296159,CDM,258,RC,,,Outpatient,,,59.3,35.58,,50.41,85,,40.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.06,32.15,,15.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.46,80.03,,37.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.37,90,,42.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.06,32.15,,15.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.3,,,,Other,Not Separately reimbursable,19.06,32.15,,15.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.18,88,,41.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.63,33.11,,15.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.06,53.37,
KIT CATH 5FR,22382,CDM,270,RC,,,Outpatient,,,59.5,35.7,,50.58,85,,40.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.13,32.15,,15.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.62,80.03,,38.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.55,90,,42.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.13,32.15,,15.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.5,,,,Other,Not Separately reimbursable,19.13,32.15,,15.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.36,88,,41.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.7,33.11,,15.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.13,53.55,
TUBE ENDOTRACHEAL 3.5 CUFFED,493700,CDM,270,RC,,,Outpatient,,,59.5,35.7,,50.58,85,,40.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.13,32.15,,15.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.62,80.03,,38.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.55,90,,42.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.13,32.15,,15.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.5,,,,Other,Not Separately reimbursable,19.13,32.15,,15.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.36,88,,41.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.7,33.11,,15.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.13,53.55,
YANKAUER SUCTION HANDLE,493832,CDM,270,RC,,,Outpatient,,,59.69,35.81,,50.74,85,,40.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.19,32.15,,15.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.77,80.03,,38.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.72,90,,42.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.19,32.15,,15.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.69,,,,Other,Not Separately reimbursable,19.19,32.15,,15.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.53,88,,42.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.76,33.11,,15.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.19,53.72,
TRACRIUM (atracurium) : 5ML,293267,CDM,250,RC,,,Outpatient,,,59.74,35.84,,50.78,85,,40.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.81,80.03,,38.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.77,90,,43.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.74,,,,Other,Not Separately reimbursable,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.57,88,,42.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.78,33.11,,15.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.21,53.77,
MONOCID: 1GM INJ,293272,CDM,250,RC,,,Outpatient,,,59.74,35.84,,50.78,85,,40.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.81,80.03,,38.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.77,90,,43.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.74,,,,Other,Not Separately reimbursable,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.57,88,,42.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.78,33.11,,15.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.21,53.77,
WESTCORT (hydro valerate)0.2% CRM 15GM,298058,CDM,250,RC,,,Outpatient,,,59.74,35.84,,50.78,85,,40.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.81,80.03,,38.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.77,90,,43.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.74,,,,Other,Not Separately reimbursable,19.21,32.15,,15.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.57,88,,42.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.78,33.11,,15.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.21,53.77,
P/T CRUTCHES,31116,CDM,270,RC,,,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
HYALOMATRIX  PER 1 SQ CM,844117,CDM,278,RC,Q4117,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
TEGRETOL (CARBAMAZEPINE),1882372,CDM,300,RC,80156,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.31,54,
ERYTHROPOIETIN  (MAYO),1882668,CDM,300,RC,82668,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.34,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.63,54,
"BODY FLUID, GLUCOSE  (MAYO)",1882948,CDM,300,RC,82945,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.93,54,
LDH ISOENZYMES  (MAYO),1883619,CDM,300,RC,83625,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.55,54,
"PHOSPHOROUS,  URINE 24 HR  (MAYO)",1884105,CDM,300,RC,84105,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,54,
Blood test to monitor for cytomegalovirus,1887006,CDM,300,RC,86644,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,54,
"CMV, IGM  (MAYO)",1887007,CDM,300,RC,86645,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.19,54,
..DECALCIFICATION,1888311,CDM,310,RC,88311,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60,,,,Other,Not Separately reimbursable,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.45,54,
THERAPUTIC RESP FUNCTION (2 OR MORE),456,CDM,419,RC,G0239,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",339,CDM,420,RC,97110,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
A technique used by physical therapists to restore normal body movement patterns,343,CDM,420,RC,97112,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
A type of physical therapy,347,CDM,420,RC,97116,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
Use of massage,350,CDM,420,RC,97124,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
BODY MECHANICS TRAINING II,352,CDM,420,RC,97139,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
Manipulation of 1 or more regions of the body,354,CDM,420,RC,97140,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
P/T CONSULT/EDUCATE II,370,CDM,420,RC,97139,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
W/C MOBILITY II,372,CDM,420,RC,97542,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.95,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.95,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
INPATIENT TRACTION ASSEMBLY II,383,CDM,420,RC,97139,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
P/T FLUIDOTHERAPY,393,CDM,420,RC,97022,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
Repeated application to one or more parts of the body,31103,CDM,420,RC,97032,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
"P/T INPATIENT EVAL, BASIC",311001,CDM,420,RC,97750,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
DO NOT USE,311002,CDM,420,RC,97750,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
A type of physical therapy,311018,CDM,420,RC,97116,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311026,CDM,420,RC,97110,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
P/T CONSULT/EDUCATE II-30 MIN.,311033,CDM,420,RC,97139,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
A technique used by physical therapists to restore normal body movement patterns,311103,CDM,420,RC,97112,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
DO NOT USE,311204,CDM,420,RC,97022,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
"P/T OUTPATIENT EVAL, BASIC",3110010,CDM,420,RC,97750,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
DO NOT USE,3112053,CDM,420,RC,97139,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
Occupational therapy,366,CDM,430,RC,97535,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
O/T COGNITIVE RETRAINING II,376,CDM,430,RC,97770,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",3391,CDM,430,RC,97110,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
A technique used by physical therapists to restore normal body movement patterns,3431,CDM,430,RC,97112,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
Use of massage,3501,CDM,430,RC,97124,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
O/T MYOFASCIAL RELEASE II,3541,CDM,430,RC,97250,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
O/T CONSULT/EDUCATE II,3701,CDM,430,RC,97139,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
O/T COGNITIVE RETRAINING',59005,CDM,430,RC,97770,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
O/T SPLINTING ASSESSMENT,59008,CDM,430,RC,97139,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
Occupational therapy,313009,CDM,430,RC,97535,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
MERREM ( meropenem)  1 GM VIAL,292141,CDM,636,RC,J2185,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.56,54,
VANCOMYCIN 500MG /NS 100ML PB,293202,CDM,636,RC,J3370,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,54,
DO NOT USE,311023,CDM,943,RC,93797,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,115.11,102,,,fee schedule,Pays at 102% of CMS APC rate,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.11,100,,,fee schedule,Pays at 100% of CMS APC rate,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
Test that detects Chlamydia,1884818,CDM,300,RC,87491,HCPCS,Outpatient,,,60.25,36.15,,51.21,85,,40.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.22,80.03,,38.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.23,90,,43.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,88,,42.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,54.23,
TRICHINELLA  AB  (MAYO),1886008,CDM,300,RC,86784,HCPCS,Outpatient,,,60.25,36.15,,51.21,85,,40.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.22,80.03,,38.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.23,90,,43.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,88,,42.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.27,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.8,54.23,
Blood test for an STD,1884819,CDM,300,RC,87591,HCPCS,Outpatient,,,60.28,36.17,,51.24,85,,40.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.24,80.03,,38.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.25,90,,43.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.05,88,,42.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.42,54.25,
SUTURE MONOSOF 4.0 BLACK 18  P-12,4993351,CDM,270,RC,,,Outpatient,,,60.31,36.19,,51.26,85,,41.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.39,32.15,,15.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.27,80.03,,38.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.28,90,,43.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.39,32.15,,15.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.39,32.15,,15.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.07,88,,42.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.97,33.11,,15.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.39,54.28,
SUTURE MAXON GREEN 01 1X30  T-12/GS-21,4999105,CDM,270,RC,,,Outpatient,,,60.31,36.19,,51.26,85,,41.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.39,32.15,,15.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.27,80.03,,38.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.28,90,,43.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.39,32.15,,15.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.39,32.15,,15.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.07,88,,42.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.97,33.11,,15.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.39,54.28,
ELECTRODE INFANT ECG,491022,CDM,270,RC,,,Outpatient,,,60.5,36.3,,51.43,85,,41.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.45,32.15,,15.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.42,80.03,,38.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.45,90,,43.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.45,32.15,,15.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.45,32.15,,15.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.24,88,,42.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.03,33.11,,16.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.45,54.45,
"ARSENIC, BLOOD  (MAYO)",1882176,CDM,300,RC,82175,HCPCS,Outpatient,,,60.5,36.3,,51.43,85,,41.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.42,80.03,,38.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.45,90,,43.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.24,88,,42.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.86,54.45,
"PROPOXYPHENE LEVEL, DARVON  (MAYO)",1884145,CDM,300,RC,82542,HCPCS,Outpatient,,,60.5,36.3,,51.43,85,,41.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.42,80.03,,38.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.45,90,,43.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.24,88,,42.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,54.45,
CPK ISOENZYMES  (MAYO),1882553,CDM,300,RC,82552,HCPCS,Outpatient,,,60.75,36.45,,51.64,85,,41.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.62,80.03,,38.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.68,90,,43.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.46,88,,42.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.84,54.68,
PROTOPAM (PRALIDOXIME) 1GM,293338,CDM,250,RC,,,Outpatient,,,60.77,36.46,,51.65,85,,41.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.54,32.15,,15.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.63,80.03,,38.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.69,90,,43.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.54,32.15,,15.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.54,32.15,,15.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.48,88,,42.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.12,33.11,,16.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.54,54.69,
TRAY VAGINAL ER,49305,CDM,270,RC,,,Outpatient,,,60.89,36.53,,51.76,85,,41.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.58,32.15,,15.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.73,80.03,,38.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.8,90,,43.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.58,32.15,,15.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.58,32.15,,15.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.58,88,,42.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.16,33.11,,16.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.58,54.8,
CIRCUIT BiPAP PATIENT,491607,CDM,270,RC,,,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.2,33.11,,16.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.61,54.9,
BELT OSTOMY APPLIANCE,493150,CDM,270,RC,,,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.2,33.11,,16.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.61,54.9,
ADAPTOR CONVERTIBLE,4980084,CDM,270,RC,,,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.2,33.11,,16.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.61,54.9,
Test of glucose level in the blood,1882950,CDM,300,RC,82950,HCPCS,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,54.9,
Test of glucose level in the blood,1882957,CDM,300,RC,82950,HCPCS,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,54.9,
"BODY FLUID, LACTATE DEHYDROGENASE (MAYO)",1882967,CDM,300,RC,83615,HCPCS,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.35,54.9,
"ANTI-E HISTOLYTICA, AMOEBA TITER  (MAYO",1886282,CDM,300,RC,86753,HCPCS,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.59,54.9,
NASALIDE NASAL SPRAY 25ML,292052,CDM,250,RC,,,Outpatient,,,61.03,36.62,,51.88,85,,41.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.62,32.15,,15.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.84,80.03,,39.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.93,90,,43.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.62,32.15,,15.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.62,32.15,,15.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.71,88,,42.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.21,33.11,,16.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.62,54.93,
CPM TREATMENT/CHECK,380,CDM,420,RC,97139,HCPCS,Outpatient,,,61.05,36.63,,51.89,85,,41.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.63,32.15,,15.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.86,80.03,,39.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.95,90,,43.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.63,32.15,,15.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.63,32.15,,15.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.72,88,,42.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.21,33.11,,16.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.63,54.95,
"Complete blood cell count, with differential white blood cells, automated",1885022,CDM,300,RC,85025,HCPCS,Outpatient,,,61.09,36.65,,51.93,85,,41.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.89,80.03,,39.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.92,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,54.98,90,,43.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.92,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.76,88,,43.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.77,54.98,
FLOXIN 0.3% OTIC 5ML,293437,CDM,250,RC,,,Outpatient,,,61.13,36.68,,51.96,85,,41.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.65,32.15,,15.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.92,80.03,,39.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.02,90,,44.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.65,32.15,,15.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.65,32.15,,15.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.79,88,,43.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.24,33.11,,16.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.65,55.02,
INTRALIPID 20%  250 ML,296428,CDM,258,RC,,,Outpatient,,,61.29,36.77,,52.1,85,,41.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.7,32.15,,15.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.05,80.03,,39.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.16,90,,44.13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.7,32.15,,15.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.7,32.15,,15.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.94,88,,43.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.29,33.11,,16.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.7,55.16,
MERCURY BLOOD (MAYO),1883825,CDM,300,RC,83825,HCPCS,Outpatient,,,61.5,36.9,,52.28,85,,41.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.22,80.03,,39.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.58,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.35,90,,44.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.58,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.12,88,,43.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.45,55.35,
"MERCURY, URINE  (MAYO)",1883826,CDM,300,RC,83825,HCPCS,Outpatient,,,61.5,36.9,,52.28,85,,41.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.22,80.03,,39.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.58,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.35,90,,44.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.58,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.12,88,,43.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.45,55.35,
STANDARD CO2 MONITORING EXHALE,30383,CDM,460,RC,,,Outpatient,,,61.5,36.9,,52.28,85,,41.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.77,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.22,80.03,,39.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.35,90,,44.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.77,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.77,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.12,88,,43.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.36,33.11,,16.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.77,55.35,
VOLTAREN (diclofenac) GEL 1%  100GM PACK,297036,CDM,250,RC,,,Outpatient,,,61.53,36.92,,52.3,85,,41.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.78,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.24,80.03,,39.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.38,90,,44.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.78,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.78,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.15,88,,43.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.37,33.11,,16.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.78,55.38,
SPONGE KERLIX SUPER,493071,CDM,270,RC,,,Outpatient,,,61.56,36.94,,52.33,85,,41.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.79,32.15,,15.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.27,80.03,,39.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.4,90,,44.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.79,32.15,,15.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.79,32.15,,15.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.17,88,,43.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.38,33.11,,16.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.79,55.4,
ANTITHROMBIN AG  (MAYO),1885297,CDM,300,RC,85301,HCPCS,Outpatient,,,61.75,37.05,,52.49,85,,41.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.42,80.03,,39.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.58,90,,44.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.34,88,,43.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.6,55.58,
ANTITHROMBIN III  (MAYO),1885300,CDM,300,RC,85301,HCPCS,Outpatient,,,61.75,37.05,,52.49,85,,41.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.42,80.03,,39.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.58,90,,44.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.34,88,,43.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.6,55.58,
SPECTAZOL (econazole) 1% CREAM 30 GM,297110,CDM,250,RC,,,Outpatient,,,61.85,37.11,,52.57,85,,42.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.88,32.15,,15.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.5,80.03,,39.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.67,90,,44.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.88,32.15,,15.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.88,32.15,,15.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.43,88,,43.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.48,33.11,,16.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.88,55.67,
HEARING/SCREENING NEWBORN,6008,CDM,479,RC,92551,HCPCS,Outpatient,,,61.91,37.15,,52.62,85,,42.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.9,32.15,,15.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.55,80.03,,39.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.72,90,,44.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.9,32.15,,15.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.9,32.15,,15.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.48,88,,43.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.5,33.11,,16.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.9,55.72,
SCISSORS MAYO,4910092,CDM,270,RC,,,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.53,33.11,,16.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.93,55.8,
PROLACTIN  (MAYO),1884146,CDM,300,RC,84146,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.37,55.8,
"PYRIDOXIC ACID, PA  (MAYO)",1884198,CDM,300,RC,83789,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,55.8,
BLEEDING TIME,1885000,CDM,300,RC,85002,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.91,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.91,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.66,55.8,
HSV TYPE II AB IGG (MAYO),1886700,CDM,300,RC,86695,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.59,55.8,
MICROSPORIDIAN DETECTION STAIN  (MAYO),1887015,CDM,300,RC,87015,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.4,55.8,
FLUID CELL COUNT/DIFF,1889051,CDM,300,RC,89051,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.71,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.71,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.21,55.8,
Allergy shot-1 shot,95115,CDM,940,RC,95115,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.53,33.11,,16.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.93,55.8,
COVER LITE HANDLE,49510,CDM,270,RC,,,Outpatient,,,62.19,37.31,,52.86,85,,42.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.99,32.15,,15.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.77,80.03,,39.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.97,90,,44.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.99,32.15,,15.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.99,32.15,,15.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.73,88,,43.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.59,33.11,,16.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.99,55.97,
STYLET 14FR INTUBATION,4985865,CDM,270,RC,,,Outpatient,,,62.19,37.31,,52.86,85,,42.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.99,32.15,,15.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.77,80.03,,39.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.97,90,,44.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.99,32.15,,15.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.99,32.15,,15.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.73,88,,43.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.59,33.11,,16.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.99,55.97,
STOCKING TED SMALL LONG,493271,CDM,270,RC,,,Outpatient,,,62.25,37.35,,52.91,85,,42.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.82,80.03,,39.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.03,90,,44.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.78,88,,43.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.61,33.11,,16.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.01,56.03,
STOCKING TED MEDIUM REGULAR,493272,CDM,270,RC,,,Outpatient,,,62.25,37.35,,52.91,85,,42.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.82,80.03,,39.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.03,90,,44.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.78,88,,43.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.61,33.11,,16.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.01,56.03,
STOCKING TED LARGE REGULAR,493274,CDM,270,RC,,,Outpatient,,,62.25,37.35,,52.91,85,,42.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.82,80.03,,39.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.03,90,,44.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.78,88,,43.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.61,33.11,,16.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.01,56.03,
STOCKING TED LARGE LONG,493275,CDM,270,RC,,,Outpatient,,,62.25,37.35,,52.91,85,,42.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.82,80.03,,39.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.03,90,,44.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.78,88,,43.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.61,33.11,,16.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.01,56.03,
STOCKING TED X-LARGE LONG,493277,CDM,270,RC,,,Outpatient,,,62.25,37.35,,52.91,85,,42.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.82,80.03,,39.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.03,90,,44.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.01,32.15,,16.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.78,88,,43.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.61,33.11,,16.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.01,56.03,
Coagulation assessment blood test,1887533,CDM,300,RC,85730,HCPCS,Outpatient,,,62.25,37.35,,52.91,85,,42.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,49.82,80.03,,39.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.03,90,,44.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.78,88,,43.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.54,56.03,
NASAL AIRWAY,13060,CDM,270,RC,,,Outpatient,,,62.5,37.5,,53.13,85,,42.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.02,80.03,,40.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.25,90,,45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55,88,,44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.69,33.11,,16.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.09,56.25,
ENDOTRACHEAL TUBE,13065,CDM,270,RC,,,Outpatient,,,62.5,37.5,,53.13,85,,42.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.02,80.03,,40.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.25,90,,45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55,88,,44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.69,33.11,,16.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.09,56.25,
Blood test to determine the concentration of lead in the blood,1883646,CDM,300,RC,83655,HCPCS,Outpatient,,,62.5,37.5,,53.13,85,,42.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.02,80.03,,40.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.25,90,,45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55,88,,44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10,56.25,
UNASYN  (amp/sulbactam) 1.5GM/NS 50ML PB,293331,CDM,636,RC,J0295,HCPCS,Outpatient,,,62.56,37.54,,53.18,85,,42.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.07,80.03,,40.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.3,90,,45.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.05,88,,44.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.05,56.3,
O/T BRACE/ORTHOTICS FIT,359,CDM,430,RC,97760,HCPCS,Outpatient,,,62.7,37.62,,53.3,85,,42.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.18,80.03,,40.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,46.26,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,56.43,90,,45.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.26,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.18,88,,44.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.76,33.11,,16.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.16,56.43,
HAND SPLINT ADJUSTMENT,391,CDM,430,RC,97504,HCPCS,Outpatient,,,62.7,37.62,,53.3,85,,42.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.18,80.03,,40.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.43,90,,45.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.18,88,,44.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.76,33.11,,16.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.16,56.43,
O/T BKA SPLINT CUSTOM,400,CDM,430,RC,L1834,HCPCS,Outpatient,,,62.7,37.62,,53.3,85,,42.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.18,80.03,,40.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.43,90,,45.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.18,88,,44.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.76,33.11,,16.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.16,56.43,
O/T FLUIDOTHERAPY,3931,CDM,430,RC,97022,HCPCS,Outpatient,,,62.7,37.62,,53.3,85,,42.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.18,80.03,,40.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,56.43,90,,45.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.18,88,,44.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.76,33.11,,16.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.16,56.43,
Use of massage,593039,CDM,430,RC,97124,HCPCS,Outpatient,,,62.7,37.62,,53.3,85,,42.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.18,80.03,,40.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,56.43,90,,45.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.16,32.15,,16.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.18,88,,44.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.76,33.11,,16.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.16,56.43,
"ETHOSUXIMDE, SERUM  (MAYO)",1880157,CDM,300,RC,80168,HCPCS,Outpatient,,,62.75,37.65,,53.34,85,,42.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.22,80.03,,40.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.48,90,,45.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.22,88,,44.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.55,56.48,
DURICEF (cefadroxil) 250MG/5ML SUSP:100M,295190,CDM,250,RC,,,Outpatient,,,62.83,37.7,,53.41,85,,42.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.2,32.15,,16.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.28,80.03,,40.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.55,90,,45.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.2,32.15,,16.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.2,32.15,,16.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.29,88,,44.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.8,33.11,,16.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.2,56.55,
BACTROBAN (mupirocin) 2% CREAM 30GM,297090,CDM,250,RC,,,Outpatient,,,62.83,37.7,,53.41,85,,42.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.2,32.15,,16.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.28,80.03,,40.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.55,90,,45.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.2,32.15,,16.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.2,32.15,,16.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.29,88,,44.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.8,33.11,,16.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.2,56.55,
DIPRIVAN (propofol) 10MG/ML : 50ML,293265,CDM,250,RC,,,Outpatient,,,63,37.8,,53.55,85,,42.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.42,80.03,,40.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.7,90,,45.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.44,88,,44.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.86,33.11,,16.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.25,56.7,
ANALPRAM HC (hydrocort/pramox) 2.5% 28GM,297009,CDM,250,RC,,,Outpatient,,,63,37.8,,53.55,85,,42.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.42,80.03,,40.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.7,90,,45.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.44,88,,44.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.86,33.11,,16.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.25,56.7,
MYCOSTATIN (nystatin) CREAM 30GM,297073,CDM,250,RC,,,Outpatient,,,63,37.8,,53.55,85,,42.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.42,80.03,,40.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.7,90,,45.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.44,88,,44.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.86,33.11,,16.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.25,56.7,
TRAMADOL AND METABOLITE  (MAYO),1882208,CDM,300,RC,80373,HCPCS,Outpatient,,,63,37.8,,53.55,85,,42.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.42,80.03,,40.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.7,90,,45.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.25,32.15,,16.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.44,88,,44.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.86,33.11,,16.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.25,56.7,
GEODON (ziprasidone) 20MG/ML INJ,293486,CDM,636,RC,J3486,HCPCS,Outpatient,,,63,37.8,,53.55,85,,42.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.42,80.03,,40.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.7,90,,45.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.44,88,,44.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.25,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.95,56.7,
GENTAMICIN 180MG /NS  45ML PB,296240,CDM,636,RC,J1580,HCPCS,Outpatient,,,63,37.8,,53.55,85,,42.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.42,80.03,,40.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.7,90,,45.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.44,88,,44.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.92,56.7,
DRESSING ADAPTIC 3X8,491002,CDM,270,RC,,,Outpatient,,,63.13,37.88,,53.66,85,,42.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.3,32.15,,16.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.52,80.03,,40.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.82,90,,45.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.3,32.15,,16.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.3,32.15,,16.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.55,88,,44.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.9,33.11,,16.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.3,56.82,
BAG URINARY DRAINAGE 2000ML,49556,CDM,270,RC,,,Outpatient,,,63.14,37.88,,53.67,85,,42.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.3,32.15,,16.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.53,80.03,,40.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.83,90,,45.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.3,32.15,,16.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.3,32.15,,16.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.56,88,,44.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.91,33.11,,16.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.3,56.83,
KEFLEX (cephalexin) 250MG/5ML SUSP:100ML,294041,CDM,250,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
BFO Half-sole,433,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
PEDIATRIC WRIST RESTRAINT,442,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
SLING PEDIATRIC,443,CDM,270,RC,L3670,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
K-PAD & MOTOR,49055,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
CATH FOLEY 16FR 30CC RIBBED BALLOON LUBR,49524,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
CATH FOLEY 22FR 30CC RIBBED BALLOON LUBR,49526,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
CATH FOLEY 20FR 30CC RIBBED BALLOON LUBR,49528,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
DRESSING KALTOSTAT WOUND 3X4,491516,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
CUFF PEDI/CHILD BP 1/T,493112,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
TAPE CASTING 4  WHITE DELTA LITE,493137,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
TAPE CASTING 5  WHITE DELTA LITE,493138,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
WAFFER SUR-FIT FLEXIBLE 1 1/4,493200,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
GEL HYDROACTIVE DUODERM,493260,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
DRESSING DUODERM SPIRAL HYDROCOLLOID,493263,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
CVP MANOMETER W/18G THINWALL,496460,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
TUBING PRESSURE W/M/F CONNECTION,497560,CDM,270,RC,,,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
WARM & FORM BINDER (ONLY),3110003,CDM,270,RC,L0625,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,53.05,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.05,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
ROTAVIRUS AG,1886317,CDM,300,RC,86759,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.59,56.93,
GIARDIA AG,1886321,CDM,300,RC,87329,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.21,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.21,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,56.93,
CRYPTOSPORIDIUM AG,1887206,CDM,300,RC,87328,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,56.93,
Test of a wound for type of bacterial infection,1889057,CDM,300,RC,87077,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.16,56.93,
INJECT SHOULDER ARTROGRAM,22170,CDM,320,RC,23350,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
INJECT KNEE ARTROGRAM,22178,CDM,320,RC,27370,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
INJECTION FOR HIP ARTHROGRAM,22335,CDM,320,RC,27093,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
INJECTION FOR VENOGRAM,22338,CDM,320,RC,36005,HCPCS,Outpatient,,,63.25,37.95,,53.76,85,,43.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.62,80.03,,40.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.93,90,,45.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.33,32.15,,16.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.66,88,,44.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.94,33.11,,16.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.33,56.93,
AMIDATE (etomidate) 20MG/10ML AMP,293256,CDM,250,RC,,,Outpatient,,,63.3,37.98,,53.81,85,,43.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.35,32.15,,16.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.66,80.03,,40.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.97,90,,45.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.35,32.15,,16.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.35,32.15,,16.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.7,88,,44.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.96,33.11,,16.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.35,56.97,
DRESSING VERSATEL 2X3 LAYER CONTACT,498014,CDM,270,RC,,,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SOLUBLE FIBRIN MONOMER  (MAYO),1885204,CDM,300,RC,85366,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,82.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.83,57.15,
ANTITHROMBIN III ACTIVITY  (MAYO),1885298,CDM,300,RC,85300,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.9,57.15,
MENINGITIS ANTIGEN PANEL  (MAYO),1886185,CDM,300,RC,,,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SINGLE DRUG CLASS BY DMC  (MAYO),1890002,CDM,300,RC,80301,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SINGLE DRUG CLASS BY DMC  (MAYO),1890003,CDM,300,RC,80301,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SINGLE DRUG CLASS BY DMC  (MAYO),1890004,CDM,300,RC,80301,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SINGLE DRUG CLASS BY TLC  (MAYO),1890005,CDM,300,RC,80304,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SINGLE DRUG CLASS BY TLC  (MAYO),1890006,CDM,300,RC,80304,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SINGLE DRUG CLASS BY TLC  (MAYO),1890007,CDM,300,RC,80304,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
SINGLE DRUG CLASS BY TLC  (MAYO),1890008,CDM,300,RC,80304,HCPCS,Outpatient,,,63.5,38.1,,53.98,85,,43.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.82,80.03,,40.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.15,90,,45.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.42,32.15,,16.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.88,88,,44.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.02,33.11,,16.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.42,57.15,
"HETEROPHILE, AB  (MAYO)",1886310,CDM,300,RC,86308,HCPCS,Outpatient,,,63.75,38.25,,54.19,85,,43.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.02,80.03,,40.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,57.38,90,,45.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.1,88,,44.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,57.38,
VANCOMYCIN TROUGH,1880043,CDM,300,RC,80202,HCPCS,Outpatient,,,63.76,38.26,,54.2,85,,43.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.03,80.03,,40.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,57.38,90,,45.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.11,88,,44.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.27,57.38,
TRANSFERRIN (TIBC),1886999,CDM,300,RC,84466,HCPCS,Outpatient,,,63.76,38.26,,54.2,85,,43.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.03,80.03,,40.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,57.38,90,,45.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.11,88,,44.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.54,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.06,57.38,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",3974,CDM,420,RC,97530,HCPCS,Outpatient,,,63.96,38.38,,54.37,85,,43.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.56,32.15,,16.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.19,80.03,,40.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,57.56,90,,46.05,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.56,32.15,,16.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.56,32.15,,16.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.28,88,,45.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.18,33.11,,16.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.56,57.56,
BOARD ARM NEONATAL,492240,CDM,270,RC,,,Outpatient,,,64,38.4,,54.4,85,,43.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.22,80.03,,40.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.6,90,,46.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.32,88,,45.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.19,33.11,,16.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.58,57.6,
ALPHA SUBUNIT PITUITARY MARKER  (MAYO),1884307,CDM,300,RC,83520,HCPCS,Outpatient,,,64,38.4,,54.4,85,,43.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.22,80.03,,40.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,57.6,90,,46.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.32,88,,45.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,57.6,
CEFOTAN (CEFOTETAN) : 2GM VIAL,293397,CDM,250,RC,S0074,HCPCS,Outpatient,,,64.12,38.47,,54.5,85,,43.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.61,32.15,,16.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.32,80.03,,41.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.71,90,,46.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.61,32.15,,16.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.61,32.15,,16.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.43,88,,45.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.23,33.11,,16.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.61,57.71,
CATH FOLEY 14FR COUDE TIEMANN 2-WAY,49429,CDM,270,RC,,,Outpatient,,,64.25,38.55,,54.61,85,,43.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.66,32.15,,16.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.42,80.03,,41.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.83,90,,46.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.66,32.15,,16.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.66,32.15,,16.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.54,88,,45.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.27,33.11,,17.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.66,57.83,
STOPS-BLEEDING 200 GRAM POUCH,491000,CDM,270,RC,,,Outpatient,,,64.25,38.55,,54.61,85,,43.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.66,32.15,,16.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.42,80.03,,41.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.83,90,,46.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.66,32.15,,16.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.66,32.15,,16.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.54,88,,45.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.27,33.11,,17.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.66,57.83,
TRAY CATH URETHRAL 14FR,49568,CDM,270,RC,,,Outpatient,,,64.37,38.62,,54.71,85,,43.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.69,32.15,,16.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.52,80.03,,41.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.93,90,,46.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.69,32.15,,16.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.69,32.15,,16.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.65,88,,45.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.31,33.11,,17.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.69,57.93,
CYANIDE (MAYO),1882111,CDM,300,RC,82600,HCPCS,Outpatient,,,64.5,38.7,,54.83,85,,43.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.62,80.03,,41.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.05,90,,46.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.76,88,,45.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.4,58.05,
ATROP  (atropine) 1% OPTH SOL 5ML,297777,CDM,250,RC,,,Outpatient,,,64.55,38.73,,54.87,85,,43.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.75,32.15,,16.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.66,80.03,,41.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.1,90,,46.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.75,32.15,,16.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.75,32.15,,16.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.8,88,,45.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.37,33.11,,17.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.75,58.1,
SPLINT COCKUP SMALL,490100,CDM,270,RC,,,Outpatient,,,64.75,38.85,,55.04,85,,44.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.82,80.03,,41.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.28,90,,46.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.98,88,,45.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.44,33.11,,17.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.82,58.28,
SPLINT COCKUP MEDIUM,490101,CDM,270,RC,,,Outpatient,,,64.75,38.85,,55.04,85,,44.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.82,80.03,,41.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.28,90,,46.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.98,88,,45.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.44,33.11,,17.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.82,58.28,
SPLINT COCK-UP LARGE,490102,CDM,270,RC,,,Outpatient,,,64.75,38.85,,55.04,85,,44.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.82,80.03,,41.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.28,90,,46.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.82,32.15,,16.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.98,88,,45.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.44,33.11,,17.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.82,58.28,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1884812,CDM,300,RC,83516,HCPCS,Outpatient,,,64.75,38.85,,55.04,85,,44.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.82,80.03,,41.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.28,90,,46.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.98,88,,45.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,58.28,
ANAEROBIC SUSC PER AGENT (MAYO),1884893,CDM,300,RC,87181,HCPCS,Outpatient,,,64.75,38.85,,55.04,85,,44.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.82,80.03,,41.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.28,90,,46.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.98,88,,45.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,58.28,
TIMENTIN: 3.1GM VIAL,293383,CDM,250,RC,,,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
EZPAP W/MOUTHPIECE,30339,CDM,270,RC,,,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
P/T SETUP BUCKS TRACTION,31107,CDM,270,RC,,,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65,,,,Other,Not Separately reimbursable,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
INDERMIL TOP ADHESIVE,298069,CDM,270,RC,,,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65,,,,Other,Not Separately reimbursable,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
SET CORD BLOOD,494716,CDM,270,RC,,,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65,,,,Other,Not Separately reimbursable,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
Blood test to determine existence of certain bacterium that causes syphilis,1884913,CDM,300,RC,86780,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
LIVER PROFILE (INACTIVE),1886074,CDM,300,RC,,,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
..DERMA-PATH(TISSUE),1888306,CDM,310,RC,88304,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.18,58.5,
Manipulation of 1 or more regions of the body,358,CDM,420,RC,97140,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
O/T JOINT/SPINAL MOBILIZATION II,3581,CDM,430,RC,97265,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",313012,CDM,430,RC,97110,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
A technique used by physical therapists to restore normal body movement patterns,313027,CDM,430,RC,97112,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
A technique used by physical therapists to restore normal body movement patterns,313028,CDM,430,RC,97112,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
Therapy for speech or hearing,312004,CDM,440,RC,92507,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.9,32.15,,16.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.52,33.11,,17.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.9,58.5,
MERREM ( meropenem)  500MG / NS 50ML PB,292142,CDM,636,RC,J2185,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.56,58.5,
ZOSYN (pipracil/tazo) 3.375GM/NS100PB,293304,CDM,636,RC,J2543,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.89,58.5,
PRIMAXIN  (imipenem) 250MG /100ML NSPB,293521,CDM,636,RC,J0743,HCPCS,Outpatient,,,65,39,,55.25,85,,44.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.02,80.03,,41.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,46.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.2,88,,45.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.93,58.5,
TEMOVATE 0.05% CREAM 30GM,297065,CDM,250,RC,,,Outpatient,,,65.15,39.09,,55.38,85,,44.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.95,32.15,,16.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.14,80.03,,41.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.64,90,,46.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.95,32.15,,16.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.95,32.15,,16.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.33,88,,45.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.57,33.11,,17.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.95,58.64,
SITZ BATH,493022,CDM,270,RC,,,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.6,33.11,,17.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.98,58.73,
STOCKING TED X-LARGE REGULAR,493276,CDM,270,RC,,,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.6,33.11,,17.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.98,58.73,
CREATININE CLEARANCE,1882575,CDM,300,RC,82575,HCPCS,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.64,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.64,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.88,58.73,
Blood test to determine the concentration of lead in the blood,1883040,CDM,300,RC,83655,HCPCS,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10,58.73,
"LEGIONELLA  AG, URINE  (MAYO)",1883520,CDM,300,RC,87899,HCPCS,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,58.73,
LUPUS ANTICOAGULANT PROFILE  (MAYO),1885302,CDM,300,RC,85705,HCPCS,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.11,58.73,
"COMPLEMENT TOTAL, CH-50  (MAYO)",1886162,CDM,300,RC,86162,HCPCS,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.72,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.72,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.55,58.73,
Repeated application to one or more parts of the body,3261,CDM,430,RC,97032,HCPCS,Outpatient,,,65.25,39.15,,55.46,85,,44.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.22,80.03,,41.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,58.73,90,,46.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,20.98,32.15,,16.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.42,88,,45.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.6,33.11,,17.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.98,58.73,
CATH ULTRAMER 16FR URETHRAL RED RUBBER,49620,CDM,270,RC,,,Outpatient,,,65.31,39.19,,55.51,85,,44.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21,32.15,,16.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.27,80.03,,41.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.78,90,,47.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21,32.15,,16.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21,32.15,,16.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.47,88,,45.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.62,33.11,,17.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21,58.78,
FIBRINOGEN,1885376,CDM,300,RC,85384,HCPCS,Outpatient,,,65.75,39.45,,55.89,85,,44.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.62,80.03,,42.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.91,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.18,90,,47.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.91,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.86,88,,46.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.68,59.18,
MRI TISSUE MARKER PLACEMENT,27093,CDM,320,RC,19287,HCPCS,Outpatient,,,65.75,39.45,,55.89,85,,44.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.14,32.15,,16.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.62,80.03,,42.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.16,102,,,fee schedule,Pays at 102% of CMS APC rate,59.18,90,,47.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.14,32.15,,16.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.16,100,,,fee schedule,Pays at 100% of CMS APC rate,21.14,32.15,,16.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.86,88,,46.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.77,33.11,,17.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.14,59.18,
.INCENTIVE SPIROMETRY DISPOSIBLE,30350,CDM,270,RC,,,Outpatient,,,65.81,39.49,,55.94,85,,44.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.16,32.15,,16.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.67,80.03,,42.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.23,90,,47.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.16,32.15,,16.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.16,32.15,,16.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.91,88,,46.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.79,33.11,,17.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.16,59.23,
CANISTER 45ML PREVENA,4901095,CDM,270,RC,,,Outpatient,,,65.9,39.54,,56.02,85,,44.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.19,32.15,,16.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.74,80.03,,42.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.31,90,,47.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.19,32.15,,16.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.19,32.15,,16.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.99,88,,46.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.82,33.11,,17.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.19,59.31,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",14323,CDM,260,RC,96376,HCPCS,Outpatient,,,65.94,39.56,,56.05,85,,44.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.2,32.15,,16.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.77,80.03,,42.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.35,90,,47.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.2,32.15,,16.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.2,32.15,,16.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.03,88,,46.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.83,33.11,,17.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.2,59.35,
DIGOXIN,1882643,CDM,300,RC,80162,HCPCS,Outpatient,,,65.94,39.56,,56.05,85,,44.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.77,80.03,,42.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.54,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.35,90,,47.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.54,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.03,88,,46.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.7,59.35,
VENTOLIN-HFA INHALER 8 GRAMS INST,292046,CDM,250,RC,,,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
SLING SOLO MULTISTRAP STANDARD 4 X 38 IN,492250,CDM,270,RC,,,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
STOCKING TED SMALL REGULAR,493270,CDM,270,RC,,,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
ZOSYN (pipral/tazo) 2.25 GM/ NS 50ML PB,293380,CDM,636,RC,J2543,HCPCS,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.89,59.4,
Blood test to measure a certain protein in the blood to determine heart muscle damage,1882554,CDM,300,RC,84484,HCPCS,Outpatient,,,66.22,39.73,,56.29,85,,45.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53,80.03,,42.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.71,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.6,90,,47.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.71,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.27,88,,46.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.38,59.6,
VANCOMYCIN 1.5GM /300ML PREMIXED IVPB,303454,CDM,636,RC,J3370,HCPCS,Outpatient,,,66.24,39.74,,56.3,85,,45.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.01,80.03,,42.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.62,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.29,88,,46.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,59.62,
SKIN AFFIX TOP ADHESIVE 0.7GM,297532,CDM,270,RC,,,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,33.11,,17.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.3,59.63,
STOCKING TED MEDIUM LONG,493273,CDM,270,RC,,,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,33.11,,17.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.3,59.63,
PASTE ZGUARD PHYTOPLEX 2 OZ,498019,CDM,270,RC,,,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,33.11,,17.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.3,59.63,
"ALCOHOL, SALIVA",1882057,CDM,300,RC,82055,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.3,32.15,,17.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.94,33.11,,17.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.3,59.63,
PROGESTERONE  (MAYO),1884144,CDM,300,RC,84144,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.61,59.63,
C-PEPTIDE  (MAYO),1884684,CDM,300,RC,84681,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.98,59.63,
Blood test to monitor breast cancer,1886308,CDM,300,RC,86300,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.16,59.63,
CA 19-9  (MAYO),1886315,CDM,300,RC,86301,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.16,59.63,
Blood test to monitor for cancer,1886316,CDM,300,RC,86304,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.16,59.63,
INTRINSIC FACTOR  (MAYO),1886338,CDM,300,RC,83528,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.21,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.21,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20,59.63,
A test used to determine which medications work on bacteria for fungi,1887186,CDM,300,RC,87186,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.87,59.63,
AUGMENTIN (AMOX/CLAV) 200MG/5ML : 75ML,294075,CDM,250,RC,,,Outpatient,,,66.4,39.84,,56.44,85,,45.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.35,32.15,,17.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.14,80.03,,42.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.76,90,,47.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.35,32.15,,17.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.35,32.15,,17.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.43,88,,46.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.99,33.11,,17.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.35,59.76,
STOCKING KNEE-HI SMALL LONG,493162,CDM,270,RC,,,Outpatient,,,66.5,39.9,,56.53,85,,45.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.38,32.15,,17.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.22,80.03,,42.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.85,90,,47.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.38,32.15,,17.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.38,32.15,,17.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.52,88,,46.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.02,33.11,,17.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.38,59.85,
CLONAZEPAM (KLONOPIN) (MAYO),1882512,CDM,300,RC,80346,HCPCS,Outpatient,,,66.5,39.9,,56.53,85,,45.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.22,80.03,,42.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.85,90,,47.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.52,88,,46.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.26,59.85,
EXHALED CARBON MONOXIDE,30381,CDM,410,RC,94760,HCPCS,Outpatient,,,66.5,39.9,,56.53,85,,45.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.38,32.15,,17.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.22,80.03,,42.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.85,90,,47.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.38,32.15,,17.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.38,32.15,,17.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.52,88,,46.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.02,33.11,,17.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.38,59.85,
DURAGESIC (fentanyl) 100mcg PATCH,292063,CDM,250,RC,,,Outpatient,,,66.7,40.02,,56.7,85,,45.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.44,32.15,,17.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.38,80.03,,42.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.03,90,,48.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.44,32.15,,17.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.44,32.15,,17.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.7,88,,46.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.08,33.11,,17.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.44,60.03,
SEMEN ANALYSIS (POST VASEC),1889300,CDM,300,RC,89321,HCPCS,Outpatient,,,66.9,40.14,,56.87,85,,45.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.54,80.03,,42.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,60.21,90,,48.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.87,88,,47.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.25,60.21,
..SEMEN MORPHOLOGY (SMEAR),1889301,CDM,300,RC,89300,HCPCS,Outpatient,,,66.9,40.14,,56.87,85,,45.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.54,80.03,,42.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.03,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,60.21,90,,48.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.03,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.87,88,,47.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.21,60.21,
ZOSYN (pipracil/tazo) 3.375GM/H20 50MLPB,293305,CDM,636,RC,J2543,HCPCS,Outpatient,,,67.03,40.22,,56.98,85,,45.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.64,80.03,,42.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.33,90,,48.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.99,88,,47.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.89,60.33,
"LEGGINGS, PAIR, 31X48, STERILE",499401,CDM,270,RC,,,Outpatient,,,67.19,40.31,,57.11,85,,45.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.6,32.15,,17.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.77,80.03,,43.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.47,90,,48.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.6,32.15,,17.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.6,32.15,,17.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.13,88,,47.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.25,33.11,,17.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.6,60.47,
"VITAMIN B2, RIBOFLAVIN  (MAYO)",1884252,CDM,300,RC,84252,HCPCS,Outpatient,,,67.25,40.35,,57.16,85,,45.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.82,80.03,,43.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.64,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,60.53,90,,48.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.64,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.18,88,,47.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.45,60.53,
CARDIAC STRAIN,2200399,CDM,480,RC,0399T,HCPCS,Outpatient,,,67.25,40.35,,57.16,85,,45.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.62,32.15,,17.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.82,80.03,,43.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.53,90,,48.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.62,32.15,,17.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.62,32.15,,17.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.18,88,,47.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.27,33.11,,17.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.62,60.53,
SPORANOX (itraconazole) 10MG/ML SOLN 1OZ,292339,CDM,250,RC,,,Outpatient,,,67.3,40.38,,57.21,85,,45.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.64,32.15,,17.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.86,80.03,,43.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.57,90,,48.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.64,32.15,,17.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.64,32.15,,17.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.22,88,,47.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.28,33.11,,17.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.64,60.57,
FERRLECIT 62.5MG/5ML,293462,CDM,636,RC,J2916,HCPCS,Outpatient,,,67.35,40.41,,57.25,85,,45.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,53.9,80.03,,43.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.62,90,,48.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.27,88,,47.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.1,60.62,
CLIP CORD,490808,CDM,270,RC,,,Outpatient,,,67.45,40.47,,57.33,85,,45.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.69,32.15,,17.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.98,80.03,,43.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.71,90,,48.57,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.69,32.15,,17.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.69,32.15,,17.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.36,88,,47.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.33,33.11,,17.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.69,60.71,
TISSUE CULTURE FOR NEOPLASTIC DISORDERS,2188267,CDM,310,RC,88237,HCPCS,Outpatient,,,67.5,40.5,,57.38,85,,45.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.02,80.03,,43.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,146.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,60.75,90,,48.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.4,88,,47.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,54.02,111.02,
LEUKOCYTE ALKALINE PHOSPH  (MAYO),1885540,CDM,300,RC,85540,HCPCS,Outpatient,,,67.55,40.53,,57.42,85,,45.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.06,80.03,,43.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,60.8,90,,48.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.44,88,,47.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.6,60.8,
VALPROIC ACID (DEPAKENE),1882661,CDM,300,RC,80164,HCPCS,Outpatient,,,67.7,40.62,,57.55,85,,46.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.18,80.03,,43.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,60.93,90,,48.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.58,88,,47.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.27,60.93,
"AMYLASE, BODY FLUID  (MAYO)",1882979,CDM,300,RC,82150,HCPCS,Outpatient,,,67.75,40.65,,57.59,85,,46.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.22,80.03,,43.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,60.98,90,,48.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.62,88,,47.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.15,60.98,
TESTOSTERONE TOTAL  (MAYO),1884403,CDM,300,RC,84403,HCPCS,Outpatient,,,67.86,40.72,,57.68,85,,46.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.31,80.03,,43.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.07,90,,48.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,32.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.72,88,,47.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.47,61.07,
"COOMBS, DIRECT",2086031,CDM,300,RC,86880,HCPCS,Outpatient,,,67.86,40.72,,57.68,85,,46.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.31,80.03,,43.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,61.07,90,,48.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.72,88,,47.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,61.07,
ISTAT (CREATININE-CLEARANCE),22379,CDM,300,RC,82575,HCPCS,Outpatient,,,68,40.8,,57.8,85,,46.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.42,80.03,,43.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.64,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.2,90,,48.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.64,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.84,88,,47.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.88,61.2,
CIPRO (ciprofloxacin) 200MG / D5100ML PB,293398,CDM,636,RC,J0744,HCPCS,Outpatient,,,68,40.8,,57.8,85,,46.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.86,32.15,,17.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.42,80.03,,43.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.2,90,,48.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.86,32.15,,17.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.86,32.15,,17.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.84,88,,47.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.51,33.11,,18.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.86,61.2,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",14324,CDM,260,RC,96376,HCPCS,Outpatient,,,68.13,40.88,,57.91,85,,46.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.52,80.03,,43.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.32,90,,49.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.95,88,,47.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.56,33.11,,18.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.9,61.32,
DYNA-HEX SKIN CLEANSER 4 OZ.,493015,CDM,270,RC,,,Outpatient,,,68.13,40.88,,57.91,85,,46.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.52,80.03,,43.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.32,90,,49.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.95,88,,47.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.56,33.11,,18.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.9,61.32,
DRESSING EXUDERM 6.4X6.5 ODORSHIELD,498011,CDM,270,RC,,,Outpatient,,,68.13,40.88,,57.91,85,,46.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.52,80.03,,43.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.32,90,,49.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.9,32.15,,17.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.95,88,,47.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.56,33.11,,18.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.9,61.32,
TRAZODONE   (MAYO),1880100,CDM,300,RC,80299,HCPCS,Outpatient,,,68.25,40.95,,58.01,85,,46.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.62,80.03,,43.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.43,90,,49.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.06,88,,48.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,61.43,
"THIAMINE, B-1  (MAYO)",1884208,CDM,300,RC,84425,HCPCS,Outpatient,,,68.25,40.95,,58.01,85,,46.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.62,80.03,,43.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.43,90,,49.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.06,88,,48.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.7,61.43,
INSULIN-LIKE GROWTH FACTOR (MAYO),1884306,CDM,300,RC,84305,HCPCS,Outpatient,,,68.25,40.95,,58.01,85,,46.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.62,80.03,,43.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.68,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.43,90,,49.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.68,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.06,88,,48.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.73,61.43,
CRP INFLAMMATION,1886140,CDM,300,RC,86140,HCPCS,Outpatient,,,68.25,40.95,,58.01,85,,46.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.62,80.03,,43.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.43,90,,49.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.06,88,,48.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.51,61.43,
CRP HIGH SENSITIVITY (CARDIAC),1886141,CDM,300,RC,86141,HCPCS,Outpatient,,,68.25,40.95,,58.01,85,,46.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.62,80.03,,43.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.43,90,,49.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.06,88,,48.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,61.43,
PROGRESSIVE STATIC FLEXION SPLINT,421,CDM,270,RC,,,Outpatient,,,68.3,40.98,,58.06,85,,46.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.66,80.03,,43.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.47,90,,49.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.1,88,,48.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.61,33.11,,18.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.96,61.47,
MMT-TOTAL BODY EXCLUDING HANDS,318,CDM,430,RC,95833,HCPCS,Outpatient,,,68.3,40.98,,58.06,85,,46.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.66,80.03,,43.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.47,90,,49.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.1,88,,48.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.61,33.11,,18.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.96,61.47,
WOUND MANAGEMENT III,3923,CDM,490,RC,11040,HCPCS,Outpatient,,,68.3,40.98,,58.06,85,,46.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.66,80.03,,43.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.47,90,,49.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.96,32.15,,17.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.1,88,,48.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.61,33.11,,18.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.96,61.47,
PROSTIGMIN (NEOSTIGMINE) 1:1000  10ML,293150,CDM,250,RC,,,Outpatient,,,68.5,41.1,,58.23,85,,46.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.82,80.03,,43.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.65,90,,49.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.28,88,,48.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.68,33.11,,18.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.02,61.65,
CT NEEDLE 22-20 FRANSEEN LUNG BX,26091,CDM,270,RC,,,Outpatient,,,68.5,41.1,,58.23,85,,46.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.82,80.03,,43.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.65,90,,49.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.28,88,,48.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.68,33.11,,18.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.02,61.65,
CT NEEDLE CHIBA BIOPSY DCHN 20-20,26102,CDM,270,RC,,,Outpatient,,,68.5,41.1,,58.23,85,,46.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.82,80.03,,43.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.65,90,,49.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.02,32.15,,17.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.28,88,,48.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.68,33.11,,18.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.02,61.65,
"ZINC, RBC  (MAYO)",1884631,CDM,300,RC,84630,HCPCS,Outpatient,,,68.5,41.1,,58.23,85,,46.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.82,80.03,,43.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.65,90,,49.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.28,88,,48.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.32,61.65,
HALDOL DEC (HALOPERIDOL DEC) : 50MG INJ,304883,CDM,636,RC,J1631,HCPCS,Outpatient,,,68.54,41.12,,58.26,85,,46.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,54.85,80.03,,43.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.69,90,,49.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,8.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.32,88,,48.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.04,61.69,
MASK LMA LARYNGEAL SZ3 CUFF PILOT,491950,CDM,270,RC,,,Outpatient,,,68.75,41.25,,58.44,85,,46.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.02,80.03,,44.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.88,90,,49.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.5,88,,48.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.76,33.11,,18.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.1,61.88,
MASK LMA LARYNGEAL SZ4 CUFF PILOT,491951,CDM,270,RC,,,Outpatient,,,68.75,41.25,,58.44,85,,46.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.02,80.03,,44.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.88,90,,49.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.5,88,,48.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.76,33.11,,18.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.1,61.88,
MASK LMA LARYNGEAL SZ5 CUFF PILOT,491952,CDM,270,RC,,,Outpatient,,,68.75,41.25,,58.44,85,,46.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.02,80.03,,44.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.88,90,,49.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.5,88,,48.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.76,33.11,,18.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.1,61.88,
PROSTHETIC SOCK MULTI-PLY,499929,CDM,270,RC,L8420,HCPCS,Outpatient,,,68.75,41.25,,58.44,85,,46.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.02,80.03,,44.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.88,90,,49.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.1,32.15,,17.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.5,88,,48.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.76,33.11,,18.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.1,61.88,
"HEMOGLOBIN, PLASMA  (MAYO)",1883051,CDM,300,RC,83051,HCPCS,Outpatient,,,68.75,41.25,,58.44,85,,46.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.02,80.03,,44.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.88,90,,49.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.5,88,,48.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.19,61.88,
"ZINC, URINE  (MAYO)",1884635,CDM,300,RC,84630,HCPCS,Outpatient,,,68.75,41.25,,58.44,85,,46.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.02,80.03,,44.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.88,90,,49.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.5,88,,48.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.32,61.88,
CHROMOGRANIN A  (MAYO),1886323,CDM,300,RC,86316,HCPCS,Outpatient,,,68.75,41.25,,58.44,85,,46.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.02,80.03,,44.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,61.88,90,,49.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.5,88,,48.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.16,61.88,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",3331,CDM,430,RC,97035,HCPCS,Outpatient,,,68.85,41.31,,58.52,85,,46.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.14,32.15,,17.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,80.03,,44.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,61.97,90,,49.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.14,32.15,,17.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,22.14,32.15,,17.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.59,88,,48.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.8,33.11,,18.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.14,61.97,
ACTHAR : 40 UNITS,293226,CDM,250,RC,,,Outpatient,,,69,41.4,,58.65,85,,46.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.22,80.03,,44.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.1,90,,49.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.72,88,,48.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.85,33.11,,18.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.18,62.1,
CLEOCIN  (clindamycin) 300MG/D5W 50ML PB,293882,CDM,250,RC,S0077,HCPCS,Outpatient,,,69,41.4,,58.65,85,,46.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.22,80.03,,44.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.1,90,,49.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.72,88,,48.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.85,33.11,,18.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.18,62.1,
GOWN BAIR PAWS FLEX STANDARD,499858,CDM,270,RC,,,Outpatient,,,69,41.4,,58.65,85,,46.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.22,80.03,,44.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.1,90,,49.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.18,32.15,,17.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.72,88,,48.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.85,33.11,,18.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.18,62.1,
CAPNOGRAPHY SET-UP,30022,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
.BUBBLE HUMIDIFIER,30185,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
.CONCHA PAK,30225,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
NASAL CPAP 2.5,30254,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
NASAL CPAP 3.0,30304,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
NASAL CPAP 3.5,30354,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
NASAL CPAP 4.0,30404,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
BOOKLET CRITICAL CARE,49103,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
CIRCUMCISION TRAY (DISPOSIBLE),49112,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
CANNULA  J  SHAPED 27 GUAGE,491538,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
NEEDLE SPINAL SPINOCAN 25GA X 3 1/2,491663,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
PITOCIN PUMP OB,491993,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
ALIGIDERM CALCIUM ALGINATE WOUND PACKAGE,493261,CDM,270,RC,,,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
Liver function blood test panel,1880058,CDM,300,RC,80076,HCPCS,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.28,62.33,
"ESTROGENS, TOTAL  (MAYO)",1882672,CDM,300,RC,82672,HCPCS,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.94,62.33,
"BRUCELLA  AB, SERUM  (MAYO)",1886000,CDM,300,RC,86622,HCPCS,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.23,62.33,
"CRYPTOCOCCUS AG, CSF  (MAYO)",1887210,CDM,300,RC,87899,HCPCS,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,62.33,
**TEST**,30001,CDM,410,RC,94650,HCPCS,Outpatient,,,69.25,41.55,,58.86,85,,47.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.42,80.03,,44.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.33,90,,49.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.26,32.15,,17.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.94,88,,48.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.93,33.11,,18.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.26,62.33,
COSOPT (DORZOL/TIMOLOL) OPTH 5ML,297773,CDM,250,RC,,,Outpatient,,,69.35,41.61,,58.95,85,,47.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.3,32.15,,17.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.5,80.03,,44.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.42,90,,49.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.3,32.15,,17.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.3,32.15,,17.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.03,88,,48.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.96,33.11,,18.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.3,62.42,
TAPE CLOTH SURGICAL MEDIPORE 6 X2 YD,493568,CDM,270,RC,,,Outpatient,,,69.38,41.63,,58.97,85,,47.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.31,32.15,,17.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.52,80.03,,44.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.44,90,,49.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.31,32.15,,17.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.31,32.15,,17.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.05,88,,48.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.97,33.11,,18.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.31,62.44,
MASK ANESTHESIA CHILD LG SIZE 4,491586,CDM,270,RC,,,Outpatient,,,69.5,41.7,,59.08,85,,47.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.34,32.15,,17.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.62,80.03,,44.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.55,90,,50.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.34,32.15,,17.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.34,32.15,,17.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.16,88,,48.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.01,33.11,,18.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.34,62.55,
UNIPEN  (nafcillin) 2GM /NS 100ML PB,29689,CDM,250,RC,,,Outpatient,,,69.53,41.72,,59.1,85,,47.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.35,32.15,,17.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.64,80.03,,44.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.58,90,,50.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.35,32.15,,17.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.35,32.15,,17.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.19,88,,48.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.02,33.11,,18.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.35,62.58,
SYNTOCINON NASAL SPRAY : 2ML,297912,CDM,250,RC,,,Outpatient,,,69.53,41.72,,59.1,85,,47.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.35,32.15,,17.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.64,80.03,,44.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.58,90,,50.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.35,32.15,,17.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.35,32.15,,17.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.19,88,,48.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.02,33.11,,18.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.35,62.58,
STOCKING KNEE-HI LARGE REGULAR,493172,CDM,270,RC,,,Outpatient,,,69.69,41.81,,59.24,85,,47.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.41,32.15,,17.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.77,80.03,,44.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.72,90,,50.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.41,32.15,,17.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.41,32.15,,17.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.33,88,,49.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.07,33.11,,18.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.41,62.72,
STOCKING KNEE-HI MEDIUM REGULAR,493178,CDM,270,RC,,,Outpatient,,,69.69,41.81,,59.24,85,,47.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.41,32.15,,17.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.77,80.03,,44.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.72,90,,50.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.41,32.15,,17.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.41,32.15,,17.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.33,88,,49.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.07,33.11,,18.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.41,62.72,
...BORDETELLA PERTUSSIS AB  (MAYO),1886616,CDM,300,RC,86615,HCPCS,Outpatient,,,69.75,41.85,,59.29,85,,47.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.82,80.03,,44.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,62.78,90,,50.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.38,88,,49.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.59,62.78,
"..MYCOBACTERIA CULTURE, CONC  (MAYO)",1887213,CDM,300,RC,87015,HCPCS,Outpatient,,,69.75,41.85,,59.29,85,,47.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,55.82,80.03,,44.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,62.78,90,,50.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.38,88,,49.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.4,62.78,
PROTONIX (pantoprazole) 40MG INJ FOR PB,293438,CDM,250,RC,,,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.18,33.11,,18.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.51,63,
P/T SETUP PELVIC TRACTION,31112,CDM,270,RC,,,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.18,33.11,,18.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.51,63,
APPLICATOR FLEXITIP XL ARISTA,4910081,CDM,270,RC,,,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.18,33.11,,18.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.51,63,
THALLIUM  (MAYO),1882190,CDM,300,RC,83018,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.61,63,
"URINE CALCIUM, 24HR  (MAYO)",1882340,CDM,300,RC,82340,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.59,63,
"CITRATE, URINE (24 HR)  (MAYO)",1882506,CDM,300,RC,82507,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,34.97,63,
"URINE CITRATE, 24 HR EXCRETION  (MAYO)",1882507,CDM,300,RC,82507,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,34.97,63,
"CITRIC ACID, SERUM  MAYO",1882508,CDM,300,RC,82507,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,34.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,34.97,63,
LIPO PROTEIN PARTICLE PROFILE   (MAYO),1883704,CDM,300,RC,83704,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,34.87,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.87,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,39.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,39.67,63,
BETA-CTx  (MAYO),1882520,CDM,300,RC,82523,HCPCS,Outpatient,,,70.25,42.15,,59.71,85,,47.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.22,80.03,,44.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.05,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.23,90,,50.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.05,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.82,88,,49.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.5,63.23,
ECHOVIRUS  (MAYO),1887251,CDM,300,RC,87253,HCPCS,Outpatient,,,70.25,42.15,,59.71,85,,47.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.22,80.03,,44.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.23,90,,50.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.82,88,,49.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.48,63.23,
SUCTION TUBE ATTACH DEVICE,491553,CDM,270,RC,,,Outpatient,,,70.31,42.19,,59.76,85,,47.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.6,32.15,,18.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.27,80.03,,45.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.28,90,,50.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.6,32.15,,18.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.6,32.15,,18.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.87,88,,49.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.28,33.11,,18.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.6,63.28,
"HYDROXYPROLINE, TOTAL  (MAYO)",1883505,CDM,300,RC,83505,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.56,63.45,
RENIN  (MAYO),1884244,CDM,300,RC,84244,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.66,63.45,
DRVVT CONFIRMATION (MAYO),1885317,CDM,300,RC,85613,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.03,63.45,
"ENDOMYSIAL AB, IGA  (MAYO)",1886248,CDM,300,RC,86255,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,63.45,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,332,CDM,420,RC,97033,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.34,33.11,,18.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.67,63.45,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,3197033,CDM,420,RC,97033,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.34,33.11,,18.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.67,63.45,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,3321,CDM,430,RC,97033,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.34,33.11,,18.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.67,63.45,
O/T COGNITIVE RETRAINING,3961,CDM,430,RC,97532,HCPCS,Outpatient,,,70.5,42.3,,59.93,85,,47.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.42,80.03,,45.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.45,90,,50.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.04,88,,49.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.34,33.11,,18.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.67,63.45,
KIT SPECI-CATH FEMALE 8FR,49555,CDM,270,RC,,,Outpatient,,,70.52,42.31,,59.94,85,,47.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.44,80.03,,45.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.47,90,,50.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.67,32.15,,18.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.06,88,,49.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.35,33.11,,18.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.67,63.47,
CANISTER SUCTION 1200CC,493321,CDM,270,RC,,,Outpatient,,,70.75,42.45,,60.14,85,,48.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.75,32.15,,18.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.62,80.03,,45.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.68,90,,50.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.75,32.15,,18.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.75,32.15,,18.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.26,88,,49.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.43,33.11,,18.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.75,63.68,
TUBE ENDOTRACHEAL 2.5 N/C,493696,CDM,270,RC,,,Outpatient,,,70.75,42.45,,60.14,85,,48.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.75,32.15,,18.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.62,80.03,,45.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.68,90,,50.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.75,32.15,,18.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.75,32.15,,18.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.26,88,,49.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.43,33.11,,18.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.75,63.68,
Blood test to determine if antibodies exist for rubella,1886763,CDM,300,RC,86762,HCPCS,Outpatient,,,70.75,42.45,,60.14,85,,48.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.62,80.03,,45.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.68,90,,50.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.26,88,,49.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,63.68,
TUBE ENDOTRACHEAL 7.0 CUFFED MURPHY EYE,493740,CDM,270,RC,,,Outpatient,,,70.94,42.56,,60.3,85,,48.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.77,80.03,,45.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.85,90,,51.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.43,88,,49.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.49,33.11,,18.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.81,63.85,
TUBE ENDOTRACHEAL 7.5,493746,CDM,270,RC,,,Outpatient,,,70.94,42.56,,60.3,85,,48.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.77,80.03,,45.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.85,90,,51.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.43,88,,49.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.49,33.11,,18.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.81,63.85,
TUBE ENDOTRACHEAL 8.0,493752,CDM,270,RC,,,Outpatient,,,70.94,42.56,,60.3,85,,48.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.77,80.03,,45.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.85,90,,51.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.81,32.15,,18.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.43,88,,49.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.49,33.11,,18.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.81,63.85,
Test to determine levels of immunoglobulins in the blood,1886335,CDM,300,RC,82784,HCPCS,Outpatient,,,71,42.6,,60.35,85,,48.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,56.82,80.03,,45.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,63.9,90,,51.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.48,88,,49.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.69,63.9,
VOSOL-HC EAR DROPS 10ML,297809,CDM,250,RC,,,Outpatient,,,71.07,42.64,,60.41,85,,48.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.85,32.15,,18.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.88,80.03,,45.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.96,90,,51.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.85,32.15,,18.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.85,32.15,,18.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.54,88,,50.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.53,33.11,,18.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.85,63.96,
Blood test to if peptic ulcers are caused by a certain bacterium,1886680,CDM,300,RC,86677,HCPCS,Outpatient,,,71.25,42.75,,60.56,85,,48.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.02,80.03,,45.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.13,90,,51.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.7,88,,50.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.25,64.13,
O&P COMPLEX SPECIAL STAIN  (MAYO),1887179,CDM,300,RC,87209,HCPCS,Outpatient,,,71.25,42.75,,60.56,85,,48.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.02,80.03,,45.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.13,90,,51.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.7,88,,50.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.6,64.13,
PENICILLIN 5MU/NS 100ML PB,293134,CDM,636,RC,J2510,HCPCS,Outpatient,,,71.45,42.87,,60.73,85,,48.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.97,32.15,,18.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.18,80.03,,45.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.75,102,,,fee schedule,Pays at 102% of CMS APC rate,64.31,90,,51.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.97,32.15,,18.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.75,100,,,fee schedule,Pays at 100% of CMS APC rate,22.97,32.15,,18.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.88,88,,50.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.66,33.11,,18.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.97,64.31,
Blood test to measure an enzyme in the blood,1882626,CDM,300,RC,82627,HCPCS,Outpatient,,,71.5,42.9,,60.78,85,,48.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.22,80.03,,45.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.35,90,,51.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.92,88,,50.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.96,64.35,
CULTURE ANAEROBIC,1887076,CDM,300,RC,87075,HCPCS,Outpatient,,,71.5,42.9,,60.78,85,,48.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.22,80.03,,45.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.35,90,,51.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.92,88,,50.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.9,64.35,
LDL & HDL PARTICLES NMR   (MAYO),1883705,CDM,300,RC,83704,HCPCS,Outpatient,,,71.75,43.05,,60.99,85,,48.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.42,80.03,,45.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,34.87,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.58,90,,51.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.87,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,39.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.14,88,,50.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,39.67,64.58,
SOD. MORRHUATE,293337,CDM,250,RC,,,Outpatient,,,71.85,43.11,,61.07,85,,48.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.5,80.03,,46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.67,90,,51.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.23,88,,50.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.79,33.11,,19.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.1,64.67,
INPATIENT TRACTION ASSEMBLY,382,CDM,420,RC,97139,HCPCS,Outpatient,,,71.85,43.11,,61.07,85,,48.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.5,80.03,,46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.67,90,,51.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.23,88,,50.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.79,33.11,,19.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.1,64.67,
"R5CP/EASSSET,BSC           Ei",321,CDM,424,RC,95852,HCPCS,Outpatient,,,71.85,43.11,,61.07,85,,48.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.5,80.03,,46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.37,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,64.67,90,,51.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.37,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.23,88,,50.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.79,33.11,,19.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.1,64.67,
INPATIENT BED TRACTION TREATMENT,381,CDM,430,RC,97139,HCPCS,Outpatient,,,71.85,43.11,,61.07,85,,48.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.5,80.03,,46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.67,90,,51.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.1,32.15,,18.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.23,88,,50.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.79,33.11,,19.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.1,64.67,
FORTAZ  (ceftazidime) 1GM /NS 50ML PB,293313,CDM,636,RC,J0713,HCPCS,Outpatient,,,71.85,43.11,,61.07,85,,48.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.5,80.03,,46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.67,90,,51.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.23,88,,50.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.78,64.67,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1886252,CDM,300,RC,83516,HCPCS,Outpatient,,,71.86,43.12,,61.08,85,,48.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.51,80.03,,46.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.67,90,,51.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.24,88,,50.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,64.67,
LOVENOX (enoxaparin) : 60MG INJ,293436,CDM,250,RC,,,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.84,33.11,,19.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.15,64.8,
LEVOPHED 4MG/250ML D5W (16 MCG/ML) DRIP,293802,CDM,250,RC,,,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.84,33.11,,19.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.15,64.8,
Test to determine level of iron in the blood,1883025,CDM,300,RC,82728,HCPCS,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.13,64.8,
"LACTIC ACID, ARTERIAL",30332,CDM,300,RC,83605,HCPCS,Outpatient,,,72.16,43.3,,61.34,85,,49.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.75,80.03,,46.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.8,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,64.94,90,,51.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.8,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.5,88,,50.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.43,64.94,
EPIDURAL *NON-NARC** 100 ML OB,293591,CDM,250,RC,,,Outpatient,,,72.25,43.35,,61.41,85,,49.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.23,32.15,,18.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.82,80.03,,46.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.03,90,,52.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.23,32.15,,18.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.23,32.15,,18.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.58,88,,50.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.92,33.11,,19.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.23,65.03,
FRUCTOSAMINE  (MAYO),1882985,CDM,300,RC,82985,HCPCS,Outpatient,,,72.25,43.35,,61.41,85,,49.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,57.82,80.03,,46.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,65.03,90,,52.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.58,88,,50.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,65.03,
VIBRAMYCIN (doxycycline) : 100MG VIAL,293390,CDM,250,RC,,,Outpatient,,,72.48,43.49,,61.61,85,,49.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.3,32.15,,18.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.01,80.03,,46.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.23,90,,52.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.3,32.15,,18.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.3,32.15,,18.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.78,88,,51.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24,33.11,,19.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.3,65.23,
LOCALIZER NEEDLE FOR MAMMOGRAM,492222,CDM,270,RC,,,Outpatient,,,72.5,43.5,,61.63,85,,49.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.31,32.15,,18.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.02,80.03,,46.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.25,90,,52.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.31,32.15,,18.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.31,32.15,,18.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.8,88,,51.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24,33.11,,19.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.31,65.25,
"URIC ACID, 24HR URINE (MAYO)",1884560,CDM,300,RC,84560,HCPCS,Outpatient,,,72.5,43.5,,61.63,85,,49.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.02,80.03,,46.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,65.25,90,,52.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.8,88,,51.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,65.25,
"ANA, HEP-2  (MAYO)",1886250,CDM,300,RC,86038,HCPCS,Outpatient,,,72.5,43.5,,61.63,85,,49.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.02,80.03,,46.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,65.25,90,,52.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.8,88,,51.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.2,65.25,
TREATMENT ROOM,22300,CDM,761,RC,,,Outpatient,,,72.5,43.5,,61.63,85,,49.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.31,32.15,,18.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.02,80.03,,46.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.25,90,,52.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.31,32.15,,18.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.31,32.15,,18.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.8,88,,51.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24,33.11,,19.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.31,65.25,
CANISTER FLUID 1 ELBOW 2500CC,493320,CDM,270,RC,,,Outpatient,,,72.57,43.54,,61.68,85,,49.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.33,32.15,,18.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,80.03,,46.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.31,90,,52.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.33,32.15,,18.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.33,32.15,,18.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.86,88,,51.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.03,33.11,,19.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.33,65.31,
FORCEP SPONGE 9 1/2  DISPOSABLE,4910089,CDM,270,RC,,,Outpatient,,,72.98,43.79,,62.03,85,,49.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.46,32.15,,18.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.41,80.03,,46.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.68,90,,52.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.46,32.15,,18.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.46,32.15,,18.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.22,88,,51.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.16,33.11,,19.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.46,65.68,
CEFZIL (cefprozil) 125MG/5ML SUSP: 100ML,29908,CDM,250,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
TRANEXAMIC ACID 1GM /NS 50ML PB,293018,CDM,250,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
"BACITRACIN: 50,000UNITS INJ",293033,CDM,250,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
PROTONIX (pantoprazole) 40MG PUSH,293467,CDM,250,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
TRANEXAMIC ACID 1000MG / 10ML VIAL,296101,CDM,250,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
TOBREX (tobramycin) OPHTH SOLN 5ml,297760,CDM,250,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
NS IRG 3000ML,296547,CDM,258,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 12FR 10ML 2-WAY,49424,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 14FR 10ML 2-WAY,49426,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 16FR 10ML 2-WAY,49428,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 22FR 10ML 2-WAY,49434,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 24FR 10ML 2-WAY,49436,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 26FR 10ML 2-WAY,49438,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
OCTYLSEAL TOP ADHESIVE 0.7GM,297528,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
INDERMIL TOP ADHESIVE 0.5GM,298070,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 18FR 10ML 2-WAY,491430,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
ELECTRODE BALL 3MM LLETZ DISPOSABLE,4999005,CDM,270,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
CATH FOLEY 20FR 10ML 2-WAY,49432,CDM,272,RC,,,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
DRUG SCREEN PRESCRIPTION/OTC (MAYO),1882660,CDM,300,RC,80304,HCPCS,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
SOLU MEDROL (methylprednisolone)2000 MG,293178,CDM,636,RC,J2930,HCPCS,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73,,,,Other,Not Separately reimbursable,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.99,65.7,
ZINACEF (cefuroxime)  1.5GM /SW 20ML PB,293301,CDM,636,RC,J0697,HCPCS,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73,,,,Other,Not Separately reimbursable,1.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.87,65.7,
MEFOXIN (cefoxitin)  2GM /D5 100ML PB,293562,CDM,636,RC,J0694,HCPCS,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73,,,,Other,Not Separately reimbursable,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.17,65.7,
LEVSIN (hyoscyamine) 0.5MG/ML INJ,294044,CDM,636,RC,J1980,HCPCS,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73,,,,Other,Not Separately reimbursable,35.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,35.46,65.7,
"Diphtheria, tetanus acellular, and pertussis vaccine for adults",296009,CDM,636,RC,90715,HCPCS,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73,,,,Other,Not Separately reimbursable,38.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,38.67,65.7,
SANDIMMUNE (cyclosporine) 250MG/5ML VIAL,296107,CDM,636,RC,J7516,HCPCS,Outpatient,,,73,43.8,,62.05,85,,49.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.42,80.03,,46.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.7,90,,52.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73,,,,Other,Not Separately reimbursable,23.47,32.15,,18.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.24,88,,51.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.17,33.11,,19.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.47,65.7,
NARCAN (naloxone) 2MG/500ML NS,293886,CDM,636,RC,J2310,HCPCS,Outpatient,,,73.25,43.95,,62.26,85,,49.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,58.62,80.03,,46.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.93,90,,52.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.25,,,,Other,Not Separately reimbursable,9.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.46,88,,51.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.54,65.93,
INVEGA 1.5MG TABS,304889,CDM,636,RC,,,Outpatient,,,73.27,43.96,,62.28,85,,49.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.56,32.15,,18.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.64,80.03,,46.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.94,90,,52.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.56,32.15,,18.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.27,,,,Other,Not Separately reimbursable,23.56,32.15,,18.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.48,88,,51.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.26,33.11,,19.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.56,65.94,
CETACAINE SPRAY 56GM,298047,CDM,250,RC,,,Outpatient,,,73.39,44.03,,62.38,85,,49.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.59,32.15,,18.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.73,80.03,,46.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.05,90,,52.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.59,32.15,,18.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.39,,,,Other,Not Separately reimbursable,23.59,32.15,,18.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.58,88,,51.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.3,33.11,,19.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.59,66.05,
SPORANOX 10MG/ML ORAL SOL  1 OZ,291184,CDM,250,RC,,,Outpatient,,,73.75,44.25,,62.69,85,,50.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.71,32.15,,18.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.02,80.03,,47.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.38,90,,53.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.71,32.15,,18.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.75,,,,Other,Not Separately reimbursable,23.71,32.15,,18.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.9,88,,51.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.42,33.11,,19.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.71,66.38,
PROTECTOR HEEL/ELBOW,491202,CDM,270,RC,,,Outpatient,,,73.75,44.25,,62.69,85,,50.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.71,32.15,,18.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.02,80.03,,47.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.38,90,,53.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.71,32.15,,18.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.75,,,,Other,Not Separately reimbursable,23.71,32.15,,18.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.9,88,,51.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.42,33.11,,19.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.71,66.38,
COCAINE & METABOLITE CONFIRM.  (MAYO),1882773,CDM,300,RC,80353,HCPCS,Outpatient,,,73.75,44.25,,62.69,85,,50.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.02,80.03,,47.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.38,90,,53.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,12.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.9,88,,51.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.06,66.38,
LACTIC ACID,1883605,CDM,300,RC,83605,HCPCS,Outpatient,,,73.8,44.28,,62.73,85,,50.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.06,80.03,,47.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.8,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,66.42,90,,53.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.8,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.94,88,,51.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.43,66.42,
MAXIPIME (cefepime)500MG/NS 50ML PB,303182,CDM,636,RC,,,Outpatient,,,73.8,44.28,,62.73,85,,50.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.73,32.15,,18.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.06,80.03,,47.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.42,90,,53.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.73,32.15,,18.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.73,32.15,,18.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.94,88,,51.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.44,33.11,,19.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.73,66.42,
PTH C-TERMINAL  (MAYO),1883971,CDM,300,RC,83970,HCPCS,Outpatient,,,74,44.4,,62.9,85,,50.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.22,80.03,,47.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,42.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,66.6,90,,53.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.12,88,,52.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.9,66.6,
"IMMUNHISTOCHEM STAIN, TC  (CSI)",2188330,CDM,310,RC,88341,HCPCS,Outpatient,,,74,44.4,,62.9,85,,50.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.22,80.03,,47.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.6,90,,53.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.12,88,,52.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,57.38,66.6,
CEA (MAYO),1886151,CDM,300,RC,82378,HCPCS,Outpatient,,,74.11,44.47,,62.99,85,,50.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.31,80.03,,47.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,66.7,90,,53.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.22,88,,52.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.86,66.7,
DOPPLER,49121,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
BUCKS TRACTION SPLINT - MED.,314021,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
CIRCUIT ANESTHESIA PEDIATRIC,490043,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
NEEDLE CARDIAC SPEC/TECH,491717,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
PACK BURN CARE,491782,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
SET PUMP NITRO 60 DROP,492153,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
CUFF PEDI BLOOD PRESSURE 1/T,493111,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
POUCH SUR-FIT DRAINIBLE 4,493208,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
FLANGE SUR-FIT UROSTOMY 2 3/4,493209,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
STOCKING THIGH-HI SMALL REGULAR,493256,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
DRESSING DUODERM CGF BORDER 4 X 5,493265,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
SPLINT ROLL PLASTER PER F,4910000,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
FORCEP BIOPSY HOT DISPOSABLE,4988025,CDM,270,RC,,,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
O/T HAND BASED THUMB SPICA SPLINTSUPPORT,3942,CDM,274,RC,L3800,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
"HSV-1 & HSV-2, PCR (VARIOUS)  (MAYO)",1887537,CDM,300,RC,87529,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,66.83,
P/T PARAFFIN BATH,328,CDM,420,RC,97018,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.47,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.47,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
P/T TNS MAINTENANCE/CHECK,337,CDM,420,RC,64550,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
Occupational therapy,361,CDM,420,RC,97535,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
P/T CONSULT/EDUCATE,369,CDM,420,RC,97139,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",386,CDM,420,RC,97035,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
O/T PARAFFIN BATH,3281,CDM,430,RC,97018,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.47,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.47,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
O/T TNS MAINTENANCE/CHECK,3371,CDM,430,RC,64550,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
Use of massage,3491,CDM,430,RC,97124,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
O/T CONSULT/EDUCATE,3691,CDM,430,RC,97139,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",3861,CDM,430,RC,97035,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
O/T ROM TEST - HAND,3211,CDM,434,RC,95852,HCPCS,Outpatient,,,74.25,44.55,,63.11,85,,50.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.42,80.03,,47.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.37,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,66.83,90,,53.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5.37,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.87,32.15,,19.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.34,88,,52.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,33.11,,19.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.87,66.83,
VANCENASE/BECONASE AQ. 25 GM,292107,CDM,250,RC,,,Outpatient,,,74.42,44.65,,63.26,85,,50.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.93,32.15,,19.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.56,80.03,,47.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.98,90,,53.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.93,32.15,,19.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.93,32.15,,19.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.49,88,,52.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.64,33.11,,19.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.93,66.98,
"PARVO-VIRUS, B-19, IGG/IGM   (MAYO)",1880244,CDM,300,RC,86747,HCPCS,Outpatient,,,74.5,44.7,,63.33,85,,50.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.62,80.03,,47.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.05,90,,53.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.56,88,,52.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.9,67.05,
"URINE URIC ACID, RANDOM  (MAYO)",1884561,CDM,300,RC,84560,HCPCS,Outpatient,,,74.5,44.7,,63.33,85,,50.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.62,80.03,,47.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.05,90,,53.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.56,88,,52.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,67.05,
DILUTE RUSSELL'S VIPER VENOM  (MAYO),1885613,CDM,300,RC,85613,HCPCS,Outpatient,,,74.5,44.7,,63.33,85,,50.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.62,80.03,,47.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.05,90,,53.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.56,88,,52.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.03,67.05,
INSULIN AB  (MAYO),1886337,CDM,300,RC,86337,HCPCS,Outpatient,,,74.5,44.7,,63.33,85,,50.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.62,80.03,,47.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.05,90,,53.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.56,88,,52.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.74,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.93,67.05,
PNEUMOVAX ADMIN,11018,CDM,771,RC,G0009,HCPCS,Outpatient,,,74.5,44.7,,63.33,85,,50.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.95,32.15,,19.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.62,80.03,,47.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,67.05,90,,53.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.95,32.15,,19.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,23.95,32.15,,19.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.56,88,,52.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.67,33.11,,19.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.95,67.05,
A technique used by physical therapists to restore normal body movement patterns,342,CDM,420,RC,97112,HCPCS,Outpatient,,,74.62,44.77,,63.43,85,,50.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.99,32.15,,19.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.72,80.03,,47.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,67.16,90,,53.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.99,32.15,,19.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,23.99,32.15,,19.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.67,88,,52.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.71,33.11,,19.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.99,67.16,
"UNSTABLE HEMOGLOBIN, B  (MAYO)",1883023,CDM,300,RC,83068,HCPCS,Outpatient,,,74.75,44.85,,63.54,85,,50.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.82,80.03,,47.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.28,90,,53.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.78,88,,52.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.65,67.28,
Blood test to measure a certain protein in the blood to determine heart muscle damage,1882209,CDM,300,RC,84484,HCPCS,Outpatient,,,74.9,44.94,,63.67,85,,50.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.94,80.03,,47.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.71,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.41,90,,53.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.71,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.91,88,,52.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.38,67.41,
ZOFRAN (ondansetron) 8MG/50ML NS PB,29665,CDM,250,RC,J2405,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.09,67.5,
NICOTROL INHALER #42,292115,CDM,250,RC,,,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
CLEOCIN  (clindamycin) 600MG/ D5W 50ML,293042,CDM,250,RC,S0077,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
TIMENTIN (ticarcillin):variable (3.1gm),293833,CDM,250,RC,,,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
ROXANOL (morphine CONC) 20 MG/ML BTL,299005,CDM,250,RC,,,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
EPIDURAL  NARC 100ML OB,303766,CDM,250,RC,,,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
LEVOPHED 8MG/500ML D5W (16 MCG/ML) DRIP,304538,CDM,250,RC,,,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
CORSET BRACE,31302,CDM,270,RC,,,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
CUSTOMIZED STATIC SPLINT,313002,CDM,270,RC,,,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
"Complete blood cell count, with differential white blood cells, automated",1485022,CDM,300,RC,85025,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.92,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.92,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.77,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.77,67.5,
SPEC. COLLECTION FEE-LAB (COVID),1884889,CDM,300,RC,C9803,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
HEPARIN INDUCED THROMBOCYTOPENIA  (MAYO),1886024,CDM,300,RC,86022,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.09,67.5,
MM ADD-ON 3D MAMMO BILAT,2277063,CDM,403,RC,77063,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.92,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.92,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311106,CDM,420,RC,97110,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
IVIG PREADMIN INFUSION CHARGE,293525,CDM,636,RC,G0332,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
MAG SULFATE 40GM/1000ML **OB**,296104,CDM,636,RC,J3475,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.76,67.5,
COLISTIMETHATE 150MG INJ ( COLISTIN),297111,CDM,636,RC,J0770,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.88,67.5,
MORPHINE 10MG/ML 10ML *MDV*,299076,CDM,636,RC,J2270,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.32,67.5,
ROCKY MNT SPOTTED FEVER IGG  QUEST,1886254,CDM,300,RC,86757,HCPCS,Outpatient,,,75.05,45.03,,63.79,85,,51.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.06,80.03,,48.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.55,90,,54.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.04,88,,52.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,67.55,
AMPICILLIN 2GM / NS 100ML PB,293293,CDM,636,RC,J0290,HCPCS,Outpatient,,,75.2,45.12,,63.92,85,,51.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.18,80.03,,48.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.68,90,,54.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.18,88,,52.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.95,67.68,
DRUG SCREEN 9-PANEL,1882650,CDM,300,RC,80301,HCPCS,Outpatient,,,75.25,45.15,,63.96,85,,51.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.19,32.15,,19.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.22,80.03,,48.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.73,90,,54.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.19,32.15,,19.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.19,32.15,,19.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.22,88,,52.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.92,33.11,,19.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.19,67.73,
DRESSING EAKIN FISTULA POUCH 9.7X6.3,4389,CDM,270,RC,,,Outpatient,,,75.45,45.27,,64.13,85,,51.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.26,32.15,,19.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.38,80.03,,48.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.91,90,,54.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.26,32.15,,19.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.26,32.15,,19.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.4,88,,53.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.98,33.11,,19.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.26,67.91,
CATHETER DOVER 18FR 5CC 2-WAY SILICONE,49540,CDM,270,RC,,,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
CATHETER DOVER 22FR 5CC 2-WAY SILICONE,49542,CDM,270,RC,,,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
SONOSITE NEEDLE GUIDE,65003,CDM,270,RC,,,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
CATHETER DOVER 20FR 5CC 2-WAY SILICONE,49541,CDM,272,RC,,,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
ALUMINUM  (MAYO),1882108,CDM,300,RC,82108,HCPCS,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.98,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.98,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.84,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.2,67.95,
THROMBIN TIME  (MAYO),1885733,CDM,300,RC,85670,HCPCS,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.88,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.88,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.26,67.95,
PARASITE IDENTIFICATION  (MAYO),1887169,CDM,300,RC,87169,HCPCS,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.36,67.95,
AUDITORY CANAL EXTERNAL,1488020,CDM,450,RC,,,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
PHONE CONSULT/MANAGEMENT,1499013,CDM,450,RC,,,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
HEARING/SCREENING OUTPATIENT,6007,CDM,471,RC,92551,HCPCS,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
OUTPATIENT HEARING/SCREENING,6018,CDM,479,RC,92551,HCPCS,Outpatient,,,75.5,45.3,,64.18,85,,51.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.42,80.03,,48.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,90,,54.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.27,32.15,,19.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.44,88,,53.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25,33.11,,20,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.27,67.95,
PAD TABLE OR CONVOLUTED FOAM,4999055,CDM,270,RC,,,Outpatient,,,75.63,45.38,,64.29,85,,51.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.32,32.15,,19.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.53,80.03,,48.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.07,90,,54.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.32,32.15,,19.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.32,32.15,,19.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.55,88,,53.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.04,33.11,,20.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.32,68.07,
DURICEF (CEFADROXIL) 125MG/5ML SUSP:50ML,295187,CDM,250,RC,,,Outpatient,,,75.71,45.43,,64.35,85,,51.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.34,32.15,,19.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.59,80.03,,48.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.14,90,,54.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.34,32.15,,19.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.34,32.15,,19.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.62,88,,53.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.07,33.11,,20.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.34,68.14,
IMITREX (SUMATRIPTAN) :6MG INJ,293116,CDM,636,RC,J3030,HCPCS,Outpatient,,,75.71,45.43,,64.35,85,,51.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,60.59,80.03,,48.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.14,90,,54.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.62,88,,53.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25,68.14,
BONE MARROW TRAY,2185110,CDM,270,RC,,,Outpatient,,,75.75,45.45,,64.39,85,,51.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,32.15,,19.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.62,80.03,,48.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.18,90,,54.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,32.15,,19.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.35,32.15,,19.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.66,88,,53.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,33.11,,20.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.35,68.18,
ZITHROMAX (azith) 200MG/5ML SUSP: 15ML,298019,CDM,250,RC,,,Outpatient,,,76.07,45.64,,64.66,85,,51.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.46,32.15,,19.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.88,80.03,,48.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.46,90,,54.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.46,32.15,,19.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.46,32.15,,19.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.94,88,,53.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.19,33.11,,20.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.46,68.46,
UNASYN  (amp/sulbactam) 3GM /NS100ML PB,293332,CDM,636,RC,J0295,HCPCS,Outpatient,,,76.42,45.85,,64.96,85,,51.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.16,80.03,,48.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.78,90,,55.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.25,88,,53.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.05,68.78,
ATROVENT (ipratropium) 0.03% NASAL SPRAY,292082,CDM,250,RC,,,Outpatient,,,76.48,45.89,,65.01,85,,52.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.59,32.15,,19.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.21,80.03,,48.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.83,90,,55.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.59,32.15,,19.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.59,32.15,,19.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.3,88,,53.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.32,33.11,,20.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.59,68.83,
ZOSTRIX CR 3 OZ,297072,CDM,250,RC,,,Outpatient,,,76.74,46.04,,65.23,85,,52.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,32.15,,19.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.42,80.03,,49.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.07,90,,55.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,32.15,,19.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.67,32.15,,19.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.53,88,,54.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,33.11,,20.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.67,69.07,
ABILIFY (aripiprazole) 5MG TAB,29686,CDM,250,RC,,,Outpatient,,,77,46.2,,65.45,85,,52.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.62,80.03,,49.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.3,90,,55.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.76,88,,54.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.49,33.11,,20.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.76,69.3,
ZITHROMAX (azith) 200MG/5ML SUSP:  30 ML,298072,CDM,250,RC,,,Outpatient,,,77,46.2,,65.45,85,,52.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.62,80.03,,49.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.3,90,,55.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.76,88,,54.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.49,33.11,,20.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.76,69.3,
SURGISEAL TOP ADHESIVE 0.7GM,297531,CDM,270,RC,,,Outpatient,,,77,46.2,,65.45,85,,52.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.62,80.03,,49.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.3,90,,55.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.76,32.15,,19.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.76,88,,54.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.49,33.11,,20.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.76,69.3,
VANCOMYCIN RANDOM,1880042,CDM,300,RC,80202,HCPCS,Outpatient,,,77,46.2,,65.45,85,,52.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.62,80.03,,49.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.3,90,,55.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.76,88,,54.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.27,69.3,
VANCOMYCIN PEAK,1880044,CDM,300,RC,80202,HCPCS,Outpatient,,,77,46.2,,65.45,85,,52.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.62,80.03,,49.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.3,90,,55.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.76,88,,54.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.27,69.3,
IOPIDINE 0.5% OPTH SOLN 5ML,297520,CDM,250,RC,,,Outpatient,,,77.25,46.35,,65.66,85,,52.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.84,32.15,,19.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.82,80.03,,49.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.53,90,,55.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.84,32.15,,19.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.84,32.15,,19.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.98,88,,54.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.58,33.11,,20.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.84,69.53,
DELESTROGEN *40MG/ML 1ML INJ CHG,293878,CDM,636,RC,J1380,HCPCS,Outpatient,,,77.26,46.36,,65.67,85,,52.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.84,32.15,,19.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.83,80.03,,49.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.53,90,,55.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.84,32.15,,19.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.84,32.15,,19.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.99,88,,54.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.58,33.11,,20.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.84,69.53,
Blood test to monitor vitamin D levels,1882237,CDM,300,RC,82306,HCPCS,Outpatient,,,77.29,46.37,,65.7,85,,52.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.22,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.86,80.03,,49.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.19,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.56,90,,55.65,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.22,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.19,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,37.22,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.02,88,,54.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.34,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.22,69.56,
STAT CHARGE BB,2080000,CDM,391,RC,,,Outpatient,,,77.5,46.5,,65.88,85,,52.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.92,32.15,,19.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.02,80.03,,49.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.75,90,,55.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.92,32.15,,19.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.92,32.15,,19.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.2,88,,54.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.66,33.11,,20.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.92,69.75,
GEL SILVER  ANTIMICROB SILVASORB 3 OZ,493278,CDM,270,RC,,,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.74,33.11,,20.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25,69.98,
Kidney function panel test,1880069,CDM,300,RC,80069,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.25,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.92,69.98,
FELBAMATE LEVEL  (MAYO),1882492,CDM,300,RC,80299,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,69.98,
TOBRAMYCIN TROUGH,1882628,CDM,300,RC,80200,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.84,69.98,
TOBRAMYCIN PEAK,1882629,CDM,300,RC,80200,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.84,69.98,
ESTRIOL  (MAYO),1882677,CDM,300,RC,82677,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.41,69.98,
DILANTIN (PHENYTOIN),1884045,CDM,300,RC,80185,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.67,69.98,
GENTAMICIN PEAK,1884696,CDM,300,RC,80170,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.7,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.7,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.61,69.98,
GENTAMICIN RANDOM,1884697,CDM,300,RC,80170,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.7,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.7,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.61,69.98,
A test used to determine which medications work on bacteria for fungi,1887185,CDM,300,RC,87186,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.87,69.98,
Mammography of both breasts-2 or more views,22406,CDM,403,RC,77067,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.31,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.31,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.74,33.11,,20.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25,69.98,
Mammography of both breasts-2 or more views,22407,CDM,403,RC,77067,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.31,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.31,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.74,33.11,,20.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25,69.98,
P/T 4 LAYER COMPRESSION WRAPS,39053,CDM,420,RC,29581,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.74,33.11,,20.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25,69.98,
DIGITAL BREAST TOMOSYNTHESIS; BILATERAL,2277062,CDM,614,RC,77062,HCPCS,Outpatient,,,77.75,46.65,,66.09,85,,52.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.22,80.03,,49.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.98,90,,55.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25,32.15,,20,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.42,88,,54.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.74,33.11,,20.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25,69.98,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",290083,CDM,260,RC,96366,HCPCS,Outpatient,,,77.9,46.74,,66.22,85,,52.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.04,32.15,,20.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.34,80.03,,49.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,70.11,90,,56.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.04,32.15,,20.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,25.04,32.15,,20.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.55,88,,54.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.79,33.11,,20.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.04,70.11,
CEFTIN (CEFUROXIME) 250MG/5ML : 50ML,29914,CDM,250,RC,,,Outpatient,,,78,46.8,,66.3,85,,53.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.42,80.03,,49.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.2,90,,56.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.64,88,,54.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.83,33.11,,20.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.08,70.2,
C. DIFFICLE TOXIN GENE PCR  (MAYO),1883124,CDM,300,RC,83520,HCPCS,Outpatient,,,78,46.8,,66.3,85,,53.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.42,80.03,,49.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,70.2,90,,56.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.64,88,,54.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,70.2,
MANNITOL 20% : 500ML,296266,CDM,636,RC,J2150,HCPCS,Outpatient,,,78,46.8,,66.3,85,,53.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.42,80.03,,49.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.2,90,,56.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,5.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.64,88,,54.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.26,70.2,
COCCIDIOIDES AB IGG  (MAYO),1886634,CDM,300,RC,86635,HCPCS,Outpatient,,,78.13,46.88,,66.41,85,,53.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.53,80.03,,50.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,70.32,90,,56.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.75,88,,55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.43,70.32,
COCCIDIOIDES AB IGM  (MAYO),1886635,CDM,300,RC,86635,HCPCS,Outpatient,,,78.13,46.88,,66.41,85,,53.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.53,80.03,,50.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,70.32,90,,56.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.75,88,,55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.43,70.32,
COCCIDIOIDES COMPLEMENT F  (MAYO),1886636,CDM,300,RC,86635,HCPCS,Outpatient,,,78.13,46.88,,66.41,85,,53.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.53,80.03,,50.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,70.32,90,,56.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.75,88,,55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.43,70.32,
SET CYSTO IRRIGATION UNISPIKE CONNECTOR,496471,CDM,270,RC,,,Outpatient,,,78.4,47.04,,66.64,85,,53.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.21,32.15,,20.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.74,80.03,,50.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.56,90,,56.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.21,32.15,,20.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.21,32.15,,20.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.99,88,,55.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.96,33.11,,20.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.21,70.56,
"LYSOZYME, PLASMA   (MAYO)",1885549,CDM,300,RC,85549,HCPCS,Outpatient,,,78.5,47.1,,66.73,85,,53.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.82,80.03,,50.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,70.65,90,,56.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.08,88,,55.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.59,70.65,
O/T COGNITIVE RETRAINING,375,CDM,430,RC,97532,HCPCS,Outpatient,,,78.5,47.1,,66.73,85,,53.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.24,32.15,,20.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.82,80.03,,50.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.65,90,,56.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.24,32.15,,20.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.24,32.15,,20.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.08,88,,55.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.99,33.11,,20.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.24,70.65,
"FUNGAL ID, PANEL B  (MAYO)",1887157,CDM,300,RC,87107,HCPCS,Outpatient,,,78.54,47.12,,66.76,85,,53.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.86,80.03,,50.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,70.69,90,,56.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.12,88,,55.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,70.69,
FLECAINIDE LEVEL  (MAYO),1882486,CDM,300,RC,80299,HCPCS,Outpatient,,,78.75,47.25,,66.94,85,,53.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.02,80.03,,50.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,70.88,90,,56.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.3,88,,55.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,70.88,
ZOFRAN (ondansetron) 8MG TAB,291064,CDM,636,RC,S0119,HCPCS,Outpatient,,,78.75,47.25,,66.94,85,,53.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.32,32.15,,20.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.02,80.03,,50.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.88,90,,56.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.32,32.15,,20.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.32,32.15,,20.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.3,88,,55.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.07,33.11,,20.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.32,70.88,
INTRALIPID 20%  500 ML,296425,CDM,258,RC,,,Outpatient,,,79,47.4,,67.15,85,,53.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.22,80.03,,50.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.1,90,,56.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.52,88,,55.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.16,33.11,,20.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.4,71.1,
POUCH SUR-FIT DRAINIBLE 2 3/4,493207,CDM,270,RC,,,Outpatient,,,79,47.4,,67.15,85,,53.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.22,80.03,,50.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.1,90,,56.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.52,88,,55.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.16,33.11,,20.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.4,71.1,
TESTOSTERONE FREE  (MAYO),1884402,CDM,300,RC,84402,HCPCS,Outpatient,,,79,47.4,,67.15,85,,53.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.01,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.22,80.03,,50.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.97,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.1,90,,56.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.01,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.97,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,32.01,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.52,88,,55.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.01,71.1,
Use of water for therapy/exercises,449,CDM,420,RC,97113,HCPCS,Outpatient,,,79,47.4,,67.15,85,,53.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.22,80.03,,50.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.52,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,71.1,90,,56.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.52,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.52,88,,55.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.16,33.11,,20.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.4,71.1,
Use of water for therapy/exercises,451,CDM,430,RC,97113,HCPCS,Outpatient,,,79,47.4,,67.15,85,,53.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.22,80.03,,50.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.52,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,71.1,90,,56.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.52,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,25.4,32.15,,20.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.52,88,,55.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.16,33.11,,20.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.4,71.1,
TRAY INCISION DRAINAGE,491142,CDM,270,RC,,,Outpatient,,,79.06,47.44,,67.2,85,,53.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.42,32.15,,20.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.27,80.03,,50.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.15,90,,56.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.42,32.15,,20.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.42,32.15,,20.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.57,88,,55.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.18,33.11,,20.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.42,71.15,
TAPE MICROFOAM 3,493569,CDM,270,RC,,,Outpatient,,,79.06,47.44,,67.2,85,,53.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.42,32.15,,20.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.27,80.03,,50.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.15,90,,56.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.42,32.15,,20.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.42,32.15,,20.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.57,88,,55.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.18,33.11,,20.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.42,71.15,
"LACTOFERRIN, QL, STOOL",1887900,CDM,300,RC,83630,HCPCS,Outpatient,,,79.06,47.44,,67.2,85,,53.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.27,80.03,,50.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.15,90,,56.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.57,88,,55.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,71.15,
ACYLCARNITINE  (MAYO),1882017,CDM,300,RC,82017,HCPCS,Outpatient,,,79.25,47.55,,67.36,85,,53.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.42,80.03,,50.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.33,90,,57.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.74,88,,55.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.21,71.33,
QUINIDINE  (MAYO),1884230,CDM,300,RC,80194,HCPCS,Outpatient,,,79.25,47.55,,67.36,85,,53.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.42,80.03,,50.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.33,90,,57.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.74,88,,55.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.35,71.33,
C4a  (MAYO),1886159,CDM,300,RC,86160,HCPCS,Outpatient,,,79.25,47.55,,67.36,85,,53.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.42,80.03,,50.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.33,90,,57.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.74,88,,55.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,71.33,
"CULTURE VIRUS, NON RESPIRATORY  (MAYO)",1887255,CDM,300,RC,87252,HCPCS,Outpatient,,,79.25,47.55,,67.36,85,,53.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.42,80.03,,50.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.33,90,,57.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.74,88,,55.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.8,71.33,
"VIRAL SMEAR, SHELL VIAL  (MAYO)",1887256,CDM,300,RC,87252,HCPCS,Outpatient,,,79.25,47.55,,67.36,85,,53.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.42,80.03,,50.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.33,90,,57.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.74,88,,55.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.8,71.33,
TETANUS TOX ADSORBED,296053,CDM,636,RC,90714,HCPCS,Outpatient,,,79.3,47.58,,67.41,85,,53.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.46,80.03,,50.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.37,90,,57.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,28.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.78,88,,55.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.65,71.37,
OR ISOVUE 100,22143,CDM,255,RC,,,Outpatient,,,79.31,47.59,,67.41,85,,53.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.5,32.15,,20.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.47,80.03,,50.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.38,90,,57.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.5,32.15,,20.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.5,32.15,,20.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.79,88,,55.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.26,33.11,,21.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.5,71.38,
ISOVUE 100,293402,CDM,255,RC,,,Outpatient,,,79.31,47.59,,67.41,85,,53.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.5,32.15,,20.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.47,80.03,,50.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.38,90,,57.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.5,32.15,,20.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.5,32.15,,20.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.79,88,,55.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.26,33.11,,21.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.5,71.38,
GOLYTELY  1 GAL PREP,295691,CDM,250,RC,,,Outpatient,,,79.35,47.61,,67.45,85,,53.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.51,32.15,,20.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.5,80.03,,50.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.42,90,,57.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.51,32.15,,20.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.51,32.15,,20.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.83,88,,55.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.27,33.11,,21.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.51,71.42,
SICKLE CELL SCREEN  (MAYO),1883052,CDM,300,RC,85660,HCPCS,Outpatient,,,79.5,47.7,,67.58,85,,54.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.62,80.03,,50.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.55,90,,57.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.96,88,,55.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.94,71.55,
FACTOR IX  (MAYO),1885210,CDM,300,RC,85250,HCPCS,Outpatient,,,79.5,47.7,,67.58,85,,54.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.62,80.03,,50.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.55,90,,57.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.96,88,,55.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.94,71.55,
"HEMOGLOBIN - S SCREEN, BLOOD  (MAYO)",1885660,CDM,300,RC,85660,HCPCS,Outpatient,,,79.5,47.7,,67.58,85,,54.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.62,80.03,,50.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.55,90,,57.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.96,88,,55.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.94,71.55,
HERPES SIMPLEX (PCR)  CSF (MAYO),1887525,CDM,300,RC,87529,HCPCS,Outpatient,,,79.5,47.7,,67.58,85,,54.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.62,80.03,,50.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.55,90,,57.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.96,88,,55.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,71.55,
HERPES SIMPLEX (PCR)  (MAYO),1887530,CDM,300,RC,87529,HCPCS,Outpatient,,,79.5,47.7,,67.58,85,,54.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.62,80.03,,50.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,71.55,90,,57.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.96,88,,55.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,71.55,
TISSUE GROSS ONLY,2188300,CDM,310,RC,88300,HCPCS,Outpatient,,,79.75,47.85,,67.79,85,,54.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.82,80.03,,51.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,71.78,90,,57.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.18,88,,56.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.3,71.78,
CORSET BRACE,31117,CDM,270,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
DRESSING TRANSPARENT 8X12  STERILE,49119,CDM,270,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
CONNECTOR UNIVERSAL,49823,CDM,270,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
OSTOMY DISPOS. CONVEX INSERTS,493223,CDM,270,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
CHEM 18,1880018,CDM,300,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
ETHYL (MAYO),1886808,CDM,300,RC,86757,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,72,
SLIDE REVIEW BY PATHOLOGIST,2185024,CDM,310,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
THERAPUTIC RESPIRATORY FUNCTION,455,CDM,419,RC,G0237,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.91,102,,,fee schedule,Pays at 102% of CMS APC rate,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.91,100,,,fee schedule,Pays at 100% of CMS APC rate,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
Manipulation of 1 or more regions of the body,3110014,CDM,420,RC,97140,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
PEDIATRIC EVALUATION,3195881,CDM,420,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
OT PEDIATRIC EVALUATION,313022,CDM,430,RC,97750,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
OT PEDIATRIC EVALUATION,3195882,CDM,430,RC,,,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
VANCOMYCIN 1GM /NS 250 ML IVPB,293206,CDM,636,RC,J3370,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,72,
INTRAMUSCULAR INJECTION OF ANTIBIOTIC,11011,CDM,761,RC,90788,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
INTRAVENOUS INJECTION,11013,CDM,761,RC,90784,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80,,,,Other,Not Separately reimbursable,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
NASALCROM INH,292040,CDM,250,RC,,,Outpatient,,,80.09,48.05,,68.08,85,,54.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.1,80.03,,51.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.08,90,,57.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.09,,,,Other,Not Separately reimbursable,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.48,88,,56.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.52,33.11,,21.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.75,72.08,
INTAL (CROMOLYN) INHALER,292109,CDM,250,RC,,,Outpatient,,,80.09,48.05,,68.08,85,,54.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.1,80.03,,51.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.08,90,,57.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.09,,,,Other,Not Separately reimbursable,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.48,88,,56.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.52,33.11,,21.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.75,72.08,
DURICEF (cefadroxil) 250MG/5ML SUSP:100M,295191,CDM,250,RC,,,Outpatient,,,80.09,48.05,,68.08,85,,54.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.1,80.03,,51.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.08,90,,57.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.09,,,,Other,Not Separately reimbursable,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.48,88,,56.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.52,33.11,,21.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.75,72.08,
EFUDEX 5% (5-FU) CREAM 40 GRAMS,297023,CDM,250,RC,,,Outpatient,,,80.09,48.05,,68.08,85,,54.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.1,80.03,,51.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.08,90,,57.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.09,,,,Other,Not Separately reimbursable,25.75,32.15,,20.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.48,88,,56.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.52,33.11,,21.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.75,72.08,
CLAFORAN (cefotaxime) : 2GM VIAL,293352,CDM,636,RC,J0698,HCPCS,Outpatient,,,80.09,48.05,,68.08,85,,54.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.1,80.03,,51.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.08,90,,57.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.09,,,,Other,Not Separately reimbursable,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.48,88,,56.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.8,72.08,
LEUKOCYTE FILTER ADMIN SET,20003,CDM,270,RC,,,Outpatient,,,80.25,48.15,,68.21,85,,54.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.22,80.03,,51.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.23,90,,57.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.25,,,,Other,Not Separately reimbursable,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.62,88,,56.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.57,33.11,,21.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.8,72.23,
.PEAK FLOW METER,30236,CDM,270,RC,,,Outpatient,,,80.25,48.15,,68.21,85,,54.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.22,80.03,,51.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.23,90,,57.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.25,,,,Other,Not Separately reimbursable,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.62,88,,56.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.57,33.11,,21.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.8,72.23,
CUFF ADULT X/LG 1/T BLOOD PRESSURE,493105,CDM,270,RC,,,Outpatient,,,80.25,48.15,,68.21,85,,54.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.22,80.03,,51.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.23,90,,57.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.25,,,,Other,Not Separately reimbursable,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.62,88,,56.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.57,33.11,,21.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.8,72.23,
COLLAR CERVICAL MEDIUM,491190,CDM,274,RC,L0120,HCPCS,Outpatient,,,80.25,48.15,,68.21,85,,54.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.22,80.03,,51.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.23,90,,57.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.62,88,,56.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.57,33.11,,21.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.8,72.23,
VITAL CAPACITY,30373,CDM,460,RC,94150,HCPCS,Outpatient,,,80.25,48.15,,68.21,85,,54.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.22,80.03,,51.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,72.23,90,,57.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,25.8,32.15,,20.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.62,88,,56.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.57,33.11,,21.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.8,72.23,
"GLUCAGON, PLASMA  (MAYO)",1882943,CDM,300,RC,82943,HCPCS,Outpatient,,,80.5,48.3,,68.43,85,,54.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.42,80.03,,51.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72.45,90,,57.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.84,88,,56.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.97,72.45,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",1496366,CDM,260,RC,96366,HCPCS,Outpatient,,,80.57,48.34,,68.48,85,,54.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.9,32.15,,20.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.48,80.03,,51.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,72.51,90,,58.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.9,32.15,,20.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,25.9,32.15,,20.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.9,88,,56.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.68,33.11,,21.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.9,72.51,
Blood test used to diagnose heart failure,1883527,CDM,300,RC,83880,HCPCS,Outpatient,,,80.57,48.34,,68.48,85,,54.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.48,80.03,,51.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72.51,90,,58.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.9,88,,56.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,42.69,72.51,
ZOSYN (pipracil/tazo) 4.5GM/ NS 100ML PB,293520,CDM,636,RC,J2543,HCPCS,Outpatient,,,80.6,48.36,,68.51,85,,54.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.5,80.03,,51.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.54,90,,58.03,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.6,,,,Other,Not Separately reimbursable,0.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.93,88,,56.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.89,72.54,
VANCOMYCIN 2GM /400ML IVPB PREMIXED,303455,CDM,636,RC,J3370,HCPCS,Outpatient,,,80.64,48.38,,68.54,85,,54.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.54,80.03,,51.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.58,90,,58.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.64,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.96,88,,56.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,72.58,
"CATECHOLAMINE FREE, URINE (FRACTIONATED)",1882382,CDM,300,RC,82384,HCPCS,Outpatient,,,80.75,48.45,,68.64,85,,54.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.62,80.03,,51.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72.68,90,,58.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.06,88,,56.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.75,72.68,
"LYSOZYME, SERUM  (MAYO)",1882681,CDM,300,RC,85549,HCPCS,Outpatient,,,80.75,48.45,,68.64,85,,54.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.62,80.03,,51.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72.68,90,,58.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.06,88,,56.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.59,72.68,
"MYCOBACTERIA CULTURE, CONC  (MAYO)",1887016,CDM,300,RC,87015,HCPCS,Outpatient,,,80.75,48.45,,68.64,85,,54.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.62,80.03,,51.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72.68,90,,58.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.06,88,,56.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.4,72.68,
VIRUS IDENTIFICATION  (MAYO),1887253,CDM,300,RC,87253,HCPCS,Outpatient,,,80.75,48.45,,68.64,85,,54.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.62,80.03,,51.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72.68,90,,58.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.06,88,,56.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.48,72.68,
FUNGUS ID PANEL A  (MAYO),1887797,CDM,300,RC,87107,HCPCS,Outpatient,,,80.75,48.45,,68.64,85,,54.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.62,80.03,,51.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,72.68,90,,58.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.06,88,,56.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,72.68,
MM MAMMO SCREEN EMPLOYEE,22150,CDM,403,RC,76092,HCPCS,Outpatient,,,81,48.6,,68.85,85,,55.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.04,32.15,,20.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.82,80.03,,51.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.9,90,,58.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.04,32.15,,20.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81,,,,Other,Not Separately reimbursable,26.04,32.15,,20.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.28,88,,57.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.82,33.11,,21.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.04,72.9,
MM MAMMO DIAG EMPLOYEE,22155,CDM,403,RC,77057,HCPCS,Outpatient,,,81,48.6,,68.85,85,,55.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.04,32.15,,20.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.82,80.03,,51.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.9,90,,58.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.04,32.15,,20.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81,,,,Other,Not Separately reimbursable,26.04,32.15,,20.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.28,88,,57.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.82,33.11,,21.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.04,72.9,
TOPICORT (desoximetasone) 0.25% CRM 60GM,297052,CDM,250,RC,,,Outpatient,,,81.12,48.67,,68.95,85,,55.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.08,32.15,,20.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.92,80.03,,51.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.01,90,,58.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.08,32.15,,20.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.12,,,,Other,Not Separately reimbursable,26.08,32.15,,20.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.39,88,,57.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.86,33.11,,21.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.08,73.01,
ERYTHROMYCIN : 500MG VIAL,293355,CDM,636,RC,J1364,HCPCS,Outpatient,,,81.2,48.72,,69.02,85,,55.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.98,80.03,,51.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,85.31,102,,,fee schedule,Pays at 102% of CMS APC rate,73.08,90,,58.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.31,100,,,fee schedule,Pays at 100% of CMS APC rate,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.46,88,,57.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,86.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,64.98,83.64,
CUFF PEDI BLOOD PRESSURE 2/T W/BULB,493103,CDM,270,RC,,,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.25,,,,Other,Not Separately reimbursable,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
SET IRRIGATION UNIVERSAL TWO-BOTTLE,496472,CDM,270,RC,,,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.25,,,,Other,Not Separately reimbursable,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
SET IRRIGATION TWO BAG 94,496473,CDM,270,RC,,,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.25,,,,Other,Not Separately reimbursable,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
P/T COGNITIVE RETRAINING,3972,CDM,420,RC,97532,HCPCS,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.25,,,,Other,Not Separately reimbursable,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
P/T ROM TEST- EXTREMITY OR TRUNK,320,CDM,424,RC,95851,HCPCS,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.7,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7.7,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
O/T COMMUNITY/WORK RE-INTEGRATION,3963,CDM,430,RC,97537,HCPCS,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.95,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.95,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
O/T ROM TEST - EXTREMITY AND OR TRUNK,3201,CDM,434,RC,95851,HCPCS,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.7,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7.7,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
"S/T COGNITIVE RETRAINING, EA 15-MIN",322023,CDM,440,RC,97532,HCPCS,Outpatient,,,81.25,48.75,,69.06,85,,55.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.02,80.03,,52.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.13,90,,58.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.25,,,,Other,Not Separately reimbursable,26.12,32.15,,20.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.5,88,,57.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.9,33.11,,21.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.12,73.13,
CAFCIT (caffeine cit) 20MG/ML 3ML INJ,293818,CDM,636,RC,J0706,HCPCS,Outpatient,,,81.45,48.87,,69.23,85,,55.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.19,32.15,,20.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.18,80.03,,52.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.31,90,,58.65,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.19,32.15,,20.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.45,,,,Other,Not Separately reimbursable,26.19,32.15,,20.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.68,88,,57.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.97,33.11,,21.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.19,73.31,
PSA (prostate specific antigen),1886136,CDM,300,RC,84153,HCPCS,Outpatient,,,81.56,48.94,,69.33,85,,55.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.27,80.03,,52.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,73.4,90,,58.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.77,88,,57.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.13,73.4,
TORNALATE INHALER,292051,CDM,250,RC,,,Outpatient,,,81.63,48.98,,69.39,85,,55.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.24,32.15,,20.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.33,80.03,,52.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.47,90,,58.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.24,32.15,,20.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.63,,,,Other,Not Separately reimbursable,26.24,32.15,,20.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.83,88,,57.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.03,33.11,,21.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.24,73.47,
ISTAT (CREATININE),1822379,CDM,300,RC,82575,HCPCS,Outpatient,,,81.75,49.05,,69.49,85,,55.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.42,80.03,,52.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.64,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,73.58,90,,58.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.64,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.94,88,,57.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.88,73.58,
REDUCING SUBS/STOOL  (MAYO),1881099,CDM,300,RC,84376,HCPCS,Outpatient,,,81.75,49.05,,69.49,85,,55.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.42,80.03,,52.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,73.58,90,,58.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.94,88,,57.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.92,73.58,
"DOXEPIN, S/P  (MAYO)",1882656,CDM,300,RC,80355,HCPCS,Outpatient,,,81.75,49.05,,69.49,85,,55.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.28,32.15,,21.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.42,80.03,,52.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.58,90,,58.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.28,32.15,,21.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.28,32.15,,21.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.94,88,,57.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.07,33.11,,21.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.28,73.58,
Blood test to determine cause of inappropriate blood clot formation,1886148,CDM,300,RC,86147,HCPCS,Outpatient,,,81.75,49.05,,69.49,85,,55.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.42,80.03,,52.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,73.58,90,,58.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.94,88,,57.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.99,73.58,
Blood test to determine cause of inappropriate blood clot formation,1886230,CDM,300,RC,86147,HCPCS,Outpatient,,,81.75,49.05,,69.49,85,,55.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.42,80.03,,52.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,73.58,90,,58.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.94,88,,57.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.99,73.58,
Blood test to determine cause of inappropriate blood clot formation,1886247,CDM,300,RC,86147,HCPCS,Outpatient,,,81.75,49.05,,69.49,85,,55.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.42,80.03,,52.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,73.58,90,,58.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.94,88,,57.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.99,73.58,
PT E-VISIT = OR > 21 MIN,312063,CDM,420,RC,G2063,HCPCS,Outpatient,,,81.78,49.07,,69.51,85,,55.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.29,32.15,,21.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.45,80.03,,52.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.6,90,,58.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.29,32.15,,21.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.29,32.15,,21.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.97,88,,57.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.08,33.11,,21.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.29,73.6,
"OT E-VISIT, = OR > 21 MIN",592063,CDM,420,RC,G2063,HCPCS,Outpatient,,,81.78,49.07,,69.51,85,,55.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.29,32.15,,21.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.45,80.03,,52.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.6,90,,58.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.29,32.15,,21.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.29,32.15,,21.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.97,88,,57.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.08,33.11,,21.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.29,73.6,
GENTAMICIN TROUGH,1884695,CDM,300,RC,80170,HCPCS,Outpatient,,,81.9,49.14,,69.62,85,,55.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.54,80.03,,52.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.7,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,73.71,90,,58.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.7,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.07,88,,57.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.61,73.71,
CLORPACTIN 2GM/1000ML NS IRRIGATION,299940,CDM,250,RC,,,Outpatient,,,82,49.2,,69.7,85,,55.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.36,32.15,,21.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.62,80.03,,52.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.8,90,,59.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.36,32.15,,21.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.36,32.15,,21.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.16,88,,57.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.15,33.11,,21.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.36,73.8,
SPONGE LAP 18 X 18 STERILE,493073,CDM,270,RC,,,Outpatient,,,82.19,49.31,,69.86,85,,55.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.42,32.15,,21.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.78,80.03,,52.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.97,90,,59.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.42,32.15,,21.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.42,32.15,,21.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.33,88,,57.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.21,33.11,,21.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.42,73.97,
HERPES SIMPLEX (PCR) GYN  (MAYO),1887529,CDM,300,RC,87529,HCPCS,Outpatient,,,82.5,49.5,,70.13,85,,56.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.02,80.03,,52.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.25,90,,59.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.6,88,,58.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,74.25,
PROAIR (albuterol) HFA INHALER 8.5GM,292138,CDM,250,RC,,,Outpatient,,,82.55,49.53,,70.17,85,,56.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.54,32.15,,21.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.06,80.03,,52.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.3,90,,59.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.54,32.15,,21.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.54,32.15,,21.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.64,88,,58.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.33,33.11,,21.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.54,74.3,
PROCALAMINE,296385,CDM,258,RC,,,Outpatient,,,82.66,49.6,,70.26,85,,56.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.58,32.15,,21.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.15,80.03,,52.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.39,90,,59.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.58,32.15,,21.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.58,32.15,,21.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.74,88,,58.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.37,33.11,,21.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.58,74.39,
STOCKING THIGH-HI LARGE LONG,493238,CDM,270,RC,,,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.4,33.11,,21.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.6,74.48,
STOCKING THIGH-HI LARGE REGULAR,493244,CDM,270,RC,,,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.4,33.11,,21.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.6,74.48,
STOCKING THIGH-HI X-LG LONG OVER 18,493258,CDM,270,RC,,,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.4,33.11,,21.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.6,74.48,
AMIKACIN TROUGH,1882113,CDM,300,RC,80150,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,74.48,
AMIKACIN PEAK,1882114,CDM,300,RC,80150,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,74.48,
ESTRONE  (MAYO),1882679,CDM,300,RC,82679,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.44,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.44,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.39,74.48,
"PORPHYRINS TOTAL, PLASMA  (MAYO)",1884313,CDM,300,RC,84311,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.26,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.26,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.05,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.79,74.48,
HLA B27 BLOOD  (MAYO),1886812,CDM,300,RC,86812,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,32.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.45,74.48,
CULTURE VIRUS  (MAYO),1887250,CDM,300,RC,87252,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.8,74.48,
ANTIBODY ABSORPTION,1887803,CDM,300,RC,86978,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.4,33.11,,21.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.6,74.48,
RH TYPE,2086083,CDM,300,RC,86901,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.51,74.48,
CYTO-SPIN SLIDES,2188108,CDM,310,RC,88108,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,45.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,45.74,74.48,
GROUP I FOR ID PURPOSES,2188302,CDM,310,RC,88302,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,35.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,35.06,74.48,
PATHOLOGY CONSULT (CSI),2188325,CDM,310,RC,88323,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,93.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,66.22,93.21,
"CAR SEAT EVALUATION, NEONATE, ADD 30 MIN",694781,CDM,460,RC,94781,HCPCS,Outpatient,,,82.75,49.65,,70.34,85,,56.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.22,80.03,,52.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.48,90,,59.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.6,32.15,,21.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.82,88,,58.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.4,33.11,,21.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.6,74.48,
"FOOD ALLERGEN PANEL 6, (MAYO)",1886012,CDM,300,RC,86003,HCPCS,Outpatient,,,82.78,49.67,,70.36,85,,56.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.25,80.03,,53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.5,90,,59.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.85,88,,58.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,74.5,
LEGAL BLOOD ALCOHOL / URINE DRUG SCREEN,14020,CDM,300,RC,80320,HCPCS,Outpatient,,,82.81,49.69,,70.39,85,,56.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.27,80.03,,53.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.53,90,,59.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.87,88,,58.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.59,74.53,
ZITHROMAX (azithromycin ) : 500MG VIAL,293421,CDM,250,RC,J0456,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.48,33.11,,21.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.68,74.7,
PROCTOFOAM (pramoxine) 1% 15GM,298036,CDM,250,RC,,,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.48,33.11,,21.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.68,74.7,
PCA MORPHINE 50MG/50ML,299062,CDM,250,RC,,,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.48,33.11,,21.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.68,74.7,
ZONISAMIDE  (MAYO),1882052,CDM,300,RC,80203,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.47,74.7,
ALPHA FETOPROTE (AFP) AMFL  (MAYO),1886244,CDM,300,RC,82106,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.1,74.7,
"Q FEVER AB, IGG (MAYO)",1886640,CDM,300,RC,86638,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.36,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.36,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.25,74.7,
"Q FEVER AB, IGM (MAYO)",1886643,CDM,300,RC,86638,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.36,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.36,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.71,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.25,74.7,
PROHANCE,290034,CDM,636,RC,A9576,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.68,32.15,,21.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.48,33.11,,21.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.68,74.7,
MERREM ( meropenem)  1GM / NS 50ML PB,292140,CDM,636,RC,J2185,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.56,74.7,
PRONESTYL (procainamide)500MG/ML:INJ2ML,293147,CDM,636,RC,J2690,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,340.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,340.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,340.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,350.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,66.42,340.44,
"Measles, mumps and rubella vaccine",296089,CDM,636,RC,90707,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,89.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,66.42,89.87,
PCA DEMEROL  (meperidine) 500MG/50ML,299073,CDM,636,RC,J2175,HCPCS,Outpatient,,,83,49.8,,70.55,85,,56.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.42,80.03,,53.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,59.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.04,88,,58.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.75,74.7,
CATH COUDE 18FR 10ML 2-WAY,49451,CDM,270,RC,,,Outpatient,,,83.25,49.95,,70.76,85,,56.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.62,80.03,,53.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.93,90,,59.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.26,88,,58.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.56,33.11,,22.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.76,74.93,
TUBE TRACH CANNULA INNER SPARE,493855,CDM,270,RC,,,Outpatient,,,83.25,49.95,,70.76,85,,56.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.62,80.03,,53.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.93,90,,59.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.26,88,,58.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.56,33.11,,22.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.76,74.93,
ADAPTER CONVERTIBLE S/LOCK,4980076,CDM,270,RC,,,Outpatient,,,83.25,49.95,,70.76,85,,56.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.62,80.03,,53.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.93,90,,59.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.26,88,,58.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.56,33.11,,22.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.76,74.93,
INTRAMUSCULAR INJECTION,14013,CDM,450,RC,90782,HCPCS,Outpatient,,,83.25,49.95,,70.76,85,,56.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.62,80.03,,53.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.93,90,,59.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.76,32.15,,21.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.26,88,,58.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.56,33.11,,22.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.76,74.93,
.INITIAL NEBULIZER,30265,CDM,270,RC,,,Outpatient,,,83.5,50.1,,70.98,85,,56.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.83,80.03,,53.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.15,90,,60.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.48,88,,58.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.65,33.11,,22.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.85,75.15,
URINE COLLECTOR PEDIATRIC,49072,CDM,270,RC,,,Outpatient,,,83.5,50.1,,70.98,85,,56.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.83,80.03,,53.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.15,90,,60.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.48,88,,58.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.65,33.11,,22.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.85,75.15,
WOUND VAC,3925,CDM,490,RC,,,Outpatient,,,83.5,50.1,,70.98,85,,56.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.83,80.03,,53.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.15,90,,60.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.85,32.15,,21.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.48,88,,58.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.65,33.11,,22.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.85,75.15,
RETROVIR 10MG/ML INJ (AZT) 20ML VIAL,293464,CDM,250,RC,,,Outpatient,,,83.59,50.15,,71.05,85,,56.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.87,32.15,,21.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66.9,80.03,,53.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.23,90,,60.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.87,32.15,,21.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.87,32.15,,21.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.56,88,,58.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.68,33.11,,22.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.87,75.23,
BLANKET UPPER BODY,490011,CDM,270,RC,,,Outpatient,,,83.75,50.25,,71.19,85,,56.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.93,32.15,,21.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.03,80.03,,53.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.38,90,,60.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.93,32.15,,21.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.93,32.15,,21.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.7,88,,58.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.73,33.11,,22.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.93,75.38,
"BILE ACIDS, TOTAL  (MAYO)",1882239,CDM,300,RC,82239,HCPCS,Outpatient,,,83.75,50.25,,71.19,85,,56.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.03,80.03,,53.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.46,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,75.38,90,,60.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.46,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.7,88,,58.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.55,75.38,
CORTISONE  (MAYO),1882535,CDM,300,RC,82533,HCPCS,Outpatient,,,83.75,50.25,,71.19,85,,56.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.03,80.03,,53.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,75.38,90,,60.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.7,88,,58.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.12,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.5,75.38,
"FREE CORTISOL, URINE  (MAYO)",1882536,CDM,300,RC,82530,HCPCS,Outpatient,,,83.75,50.25,,71.19,85,,56.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.03,80.03,,53.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,75.38,90,,60.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.7,88,,58.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.02,75.38,
MAXIPIME (cefepime)  1GM/50 ML NSPB,300374,CDM,636,RC,J0692,HCPCS,Outpatient,,,83.79,50.27,,71.22,85,,56.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.94,32.15,,21.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.06,80.03,,53.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.41,90,,60.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.94,32.15,,21.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.94,32.15,,21.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.74,88,,58.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.74,33.11,,22.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.94,75.41,
AMICAR (aminocap  ) 1.25GM/5ML LIQ:1OZ,292205,CDM,250,RC,,,Outpatient,,,83.95,50.37,,71.36,85,,57.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.99,32.15,,21.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.19,80.03,,53.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.56,90,,60.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.99,32.15,,21.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.99,32.15,,21.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.88,88,,59.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.8,33.11,,22.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,26.99,75.56,
PCA NUBAIN (nalbuphine) 1MG/ML 60ML,299065,CDM,250,RC,,,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.81,33.11,,22.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.01,75.6,
NEEDLE FLEXITIP SCLEROTHERAPY DISPOSABLE,491535,CDM,270,RC,,,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.81,33.11,,22.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.01,75.6,
VENLAFAXINE  (MAYO),1882498,CDM,300,RC,80299,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,75.6,
LIDOCAINE  (MAYO),1883685,CDM,300,RC,80176,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.98,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.98,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.47,75.6,
..BUN CLEARANCE,1884545,CDM,300,RC,84545,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.31,75.6,
PRIMAXIN (imipenem) :500MG VIAL,293374,CDM,636,RC,J0743,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.93,75.6,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",338,CDM,420,RC,97110,HCPCS,Outpatient,,,84.05,50.43,,71.44,85,,57.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.02,32.15,,21.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.27,80.03,,53.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,75.65,90,,60.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.02,32.15,,21.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,27.02,32.15,,21.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.96,88,,59.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.83,33.11,,22.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.02,75.65,
MIACALCIN (CALCITONIN) NASAL SPRAY 2ML,293415,CDM,250,RC,,,Outpatient,,,84.1,50.46,,71.49,85,,57.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.04,32.15,,21.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.31,80.03,,53.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.69,90,,60.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.04,32.15,,21.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.04,32.15,,21.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.01,88,,59.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.85,33.11,,22.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.04,75.69,
ZITHROMAX (azith) 200MG/5ML SUSP:22.5ML,298060,CDM,250,RC,,,Outpatient,,,84.21,50.53,,71.58,85,,57.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.07,32.15,,21.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.39,80.03,,53.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.79,90,,60.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.07,32.15,,21.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.07,32.15,,21.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.1,88,,59.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.88,33.11,,22.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.07,75.79,
ZITHROMAX (azith) 100MG/5ML SUSP:15ML,298062,CDM,250,RC,,,Outpatient,,,84.21,50.53,,71.58,85,,57.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.07,32.15,,21.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.39,80.03,,53.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.79,90,,60.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.07,32.15,,21.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.07,32.15,,21.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.1,88,,59.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.88,33.11,,22.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.07,75.79,
DRAPE TOP 102  X 53  STERILE,4994002,CDM,270,RC,,,Outpatient,,,84.3,50.58,,71.66,85,,57.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.1,32.15,,21.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.47,80.03,,53.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.87,90,,60.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.1,32.15,,21.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.1,32.15,,21.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.18,88,,59.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.91,33.11,,22.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.1,75.87,
CLAFORAN (cefotaxime) 2GM /SW 20ML PB,293041,CDM,636,RC,J0698,HCPCS,Outpatient,,,84.46,50.68,,71.79,85,,57.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.59,80.03,,54.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.01,90,,60.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.32,88,,59.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.8,76.01,
DEPO-PROVERA 150MG/ML INJ,293061,CDM,636,RC,J1050,HCPCS,Outpatient,,,84.46,50.68,,71.79,85,,57.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.59,80.03,,54.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.01,90,,60.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.32,88,,59.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.54,76.01,
ATROVENT (ipratropium) 0.06% NASAL SPRAY,292131,CDM,250,RC,,,Outpatient,,,84.5,50.7,,71.83,85,,57.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.17,32.15,,21.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.63,80.03,,54.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.05,90,,60.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.17,32.15,,21.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.17,32.15,,21.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.36,88,,59.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.98,33.11,,22.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.17,76.05,
BRACE CLAVICAL LARGE,491166,CDM,270,RC,,,Outpatient,,,84.5,50.7,,71.83,85,,57.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.17,32.15,,21.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.63,80.03,,54.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.05,90,,60.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.17,32.15,,21.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.17,32.15,,21.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.36,88,,59.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.98,33.11,,22.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.17,76.05,
O/T FINGER ORTHOSIS SPLINT,454,CDM,270,RC,L3934,HCPCS,Outpatient,,,84.65,50.79,,71.95,85,,57.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.21,32.15,,21.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.75,80.03,,54.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.19,90,,60.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.21,32.15,,21.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.21,32.15,,21.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.49,88,,59.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.03,33.11,,22.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.21,76.19,
"DRESSING, VAC GRANFOAM LARGE",43837,CDM,270,RC,,,Outpatient,,,84.75,50.85,,72.04,85,,57.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.25,32.15,,21.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.83,80.03,,54.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.28,90,,61.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.25,32.15,,21.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.25,32.15,,21.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.58,88,,59.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.06,33.11,,22.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.25,76.28,
AMYLASE ISOENZYMES  (MAYO),1882151,CDM,300,RC,82150,HCPCS,Outpatient,,,84.75,50.85,,72.04,85,,57.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.83,80.03,,54.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,76.28,90,,61.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.58,88,,59.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.15,76.28,
"PROLACTIN, TOTAL S (MAYO)",1882441,CDM,300,RC,84146,HCPCS,Outpatient,,,84.75,50.85,,72.04,85,,57.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.83,80.03,,54.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,76.28,90,,61.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.58,88,,59.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.37,76.28,
"PROLACTIN, UNPRECIPITATE, S  (MAYO)",1882442,CDM,300,RC,84146,HCPCS,Outpatient,,,84.75,50.85,,72.04,85,,57.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.83,80.03,,54.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,76.28,90,,61.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.37,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.58,88,,59.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.37,76.28,
"METHYLENEDIOXYAMPHETAMINES, MDA  (MAYO)",1882642,CDM,300,RC,80359,HCPCS,Outpatient,,,84.75,50.85,,72.04,85,,57.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.25,32.15,,21.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.83,80.03,,54.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.28,90,,61.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.25,32.15,,21.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.25,32.15,,21.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.58,88,,59.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.06,33.11,,22.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.25,76.28,
GIARDIA LAMBIA  AB PANEL  (MAYO),1886675,CDM,300,RC,86674,HCPCS,Outpatient,,,84.75,50.85,,72.04,85,,57.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.83,80.03,,54.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,76.28,90,,61.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.58,88,,59.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.5,76.28,
METHYLENE BLUE 1%,293111,CDM,250,RC,,,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
SETUP ROOM HUMIDIFIER,30050,CDM,270,RC,,,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
DRAPE ORTHOPEDIC SPLIT SHEET 77  X 108,4998301,CDM,270,RC,,,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
SLEEP APNEA MONITOR 24HR,18006,CDM,300,RC,,,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
"SOMATOMEDIN-C, PLASMA",1885001,CDM,300,RC,83520,HCPCS,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,76.5,
ADULT NEURO EVALUATION,311110,CDM,420,RC,,,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
ADULT NEURO EVALUATION,313023,CDM,430,RC,97750,HCPCS,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
ADULT NEURO EVALUATION,313033,CDM,430,RC,,,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
STOCKING THIGH-HI MEDIUM REGULAR,493250,CDM,270,RC,,,Outpatient,,,85.25,51.15,,72.46,85,,57.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.41,32.15,,21.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.23,80.03,,54.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.73,90,,61.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.41,32.15,,21.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.41,32.15,,21.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.02,88,,60.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.23,33.11,,22.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.41,76.73,
P/T FUNCTIONAL CAPACITY EVALUATION,416,CDM,424,RC,97750,HCPCS,Outpatient,,,85.4,51.24,,72.59,85,,58.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.35,80.03,,54.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,76.86,90,,61.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.15,88,,60.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.28,33.11,,22.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.46,76.86,
O/T FUNCTIONAL FCE PER 15 MIN.,3122,CDM,430,RC,97750,HCPCS,Outpatient,,,85.4,51.24,,72.59,85,,58.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.35,80.03,,54.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,76.86,90,,61.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.15,88,,60.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.28,33.11,,22.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.46,76.86,
LOGISTICARE EMS TRANSPORT,530305,CDM,540,RC,,,Outpatient,,,85.4,51.24,,72.59,85,,58.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.35,80.03,,54.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.86,90,,61.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.46,32.15,,21.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.15,88,,60.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.28,33.11,,22.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.46,76.86,
MISC DRUG 75,29910,CDM,250,RC,,,Outpatient,,,85.49,51.29,,72.67,85,,58.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.42,80.03,,54.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.94,90,,61.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.23,88,,60.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.31,33.11,,22.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.49,76.94,
BELT BODY UNIVERSAL,491092,CDM,270,RC,,,Outpatient,,,85.5,51.3,,72.68,85,,58.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.43,80.03,,54.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,61.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.24,88,,60.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.31,33.11,,22.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.49,76.95,
ELECTRODE SPIRAL QUICK CONNECT,4912001,CDM,270,RC,,,Outpatient,,,85.5,51.3,,72.68,85,,58.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.43,80.03,,54.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,61.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.24,88,,60.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.31,33.11,,22.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.49,76.95,
Pathology test,2188344,CDM,310,RC,88342,HCPCS,Outpatient,,,85.5,51.3,,72.68,85,,58.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.43,80.03,,54.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,76.95,90,,61.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.24,88,,60.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,68.43,76.95,
TELEMED FACILITY CHARGE,330001,CDM,780,RC,Q3014,HCPCS,Outpatient,,,85.5,51.3,,72.68,85,,58.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.43,80.03,,54.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,61.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.49,32.15,,21.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.24,88,,60.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.31,33.11,,22.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.49,76.95,
A type of physical therapy,346,CDM,420,RC,97116,HCPCS,Outpatient,,,85.69,51.41,,72.84,85,,58.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.55,32.15,,22.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.58,80.03,,54.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,77.12,90,,61.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.55,32.15,,22.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,27.55,32.15,,22.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.41,88,,60.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.37,33.11,,22.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.55,77.12,
CODEINE  (MAYO),1883925,CDM,300,RC,83925,HCPCS,Outpatient,,,85.75,51.45,,72.89,85,,58.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.57,32.15,,22.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.63,80.03,,54.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.18,90,,61.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.57,32.15,,22.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.57,32.15,,22.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.46,88,,60.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.39,33.11,,22.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.57,77.18,
LOVENOX (enoxaparin) : 150MG INJ,293475,CDM,250,RC,,,Outpatient,,,85.85,51.51,,72.97,85,,58.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.6,32.15,,22.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.71,80.03,,54.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.27,90,,61.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.6,32.15,,22.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.6,32.15,,22.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.55,88,,60.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.42,33.11,,22.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.6,77.27,
PAP smear,2188142,CDM,300,RC,88142,HCPCS,Outpatient,,,85.94,51.56,,73.05,85,,58.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.78,80.03,,55.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,77.35,90,,61.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.63,88,,60.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.48,77.35,
PROHANCE 15ML,275043,CDM,255,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
INTRAMUSCULAR INJECTION OF ANTIBIOTIC,11016,CDM,260,RC,96372,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
URIAS AIR SPLINT,435,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
PROBE TEMPERATURE ESOPHAGEAL/RECTAL,49583,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
BLANKET PEDIATRIC,490015,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
BRACE CLAVICAL INFANT,491165,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
DRESSING MITRAFLEX WOUND 4 X 4,491521,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
DRESSING COMBIDERM WOUND 6 X 10,491526,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
TUBE LAVAGE LAVACUATOR 32FR,491857,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
CUFF ADULT XLG 2/T W/BULB BLOOD PRESSURE,493106,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
WIRE GUIDE SUBCLAVIAN JUGULAR,496593,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
DRAPE LAPAROSCOPIC ABDOMINAL 102X121X77,4903101,CDM,270,RC,,,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
TEST CO-OXIMETRY,30342,CDM,300,RC,82805,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,80.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,35.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,35.69,77.4,
"CALCITONIN, SERUM  (MAYO)",1882308,CDM,300,RC,82308,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,33.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,33.67,77.4,
CO-OXIMETRY,1882786,CDM,300,RC,82805,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,80.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,35.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,35.69,77.4,
HYDROXYZINE (VISTARIL)  (MAYO),1883506,CDM,300,RC,83505,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.56,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.56,77.4,
TET & DIPTH TOX ADSORB ADLT,296055,CDM,636,RC,90714,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,28.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.65,77.4,
HEALTH/BEHAVIOR INCRUMENTION,458,CDM,914,RC,96152,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
ELASE OINTMENT 30GM,297016,CDM,250,RC,,,Outpatient,,,86.01,51.61,,73.11,85,,58.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.41,90,,61.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.69,88,,60.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.48,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.41,
EPOGEN *NON DIALYSIS*:4000UNITS INJ,293491,CDM,636,RC,J0885,HCPCS,Outpatient,,,86.01,51.61,,73.11,85,,58.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.23,102,,,fee schedule,Pays at 102% of CMS APC rate,77.41,90,,61.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.23,100,,,fee schedule,Pays at 100% of CMS APC rate,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.69,88,,60.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.09,77.41,
PULSE OXIMETER,14012,CDM,270,RC,,,Outpatient,,,86.25,51.75,,73.31,85,,58.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.03,80.03,,55.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.63,90,,62.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.9,88,,60.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.56,33.11,,22.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.73,77.63,
E.D. MONITOR,14018,CDM,270,RC,,,Outpatient,,,86.25,51.75,,73.31,85,,58.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.03,80.03,,55.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.63,90,,62.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.9,88,,60.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.56,33.11,,22.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.73,77.63,
INTRA ARTERIAL INJECTION,1490783,CDM,450,RC,,,Outpatient,,,86.25,51.75,,73.31,85,,58.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.03,80.03,,55.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.63,90,,62.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.73,32.15,,22.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.9,88,,60.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.56,33.11,,22.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.73,77.63,
PROLIXIN (fluphenazine)DEC 125MG/5ML INJ,293074,CDM,636,RC,J2680,HCPCS,Outpatient,,,86.4,51.84,,73.44,85,,58.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.15,80.03,,55.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.76,90,,62.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.03,88,,60.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.87,77.76,
KEPPRA (levetiracetam) 1000MG /100ML NS,304930,CDM,636,RC,J1953,HCPCS,Outpatient,,,86.4,51.84,,73.44,85,,58.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.78,32.15,,22.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.15,80.03,,55.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.76,90,,62.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.78,32.15,,22.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.78,32.15,,22.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,88,,60.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.61,33.11,,22.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.78,77.76,
Hepatitis B vaccine,293519,CDM,636,RC,90746,HCPCS,Outpatient,,,86.5,51.9,,73.53,85,,58.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.23,80.03,,55.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.85,90,,62.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,70.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.12,88,,60.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,69.23,77.85,
DANTRIUM  20MG (dantrolene) INJ,293268,CDM,250,RC,,,Outpatient,,,86.52,51.91,,73.54,85,,58.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.82,32.15,,22.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.24,80.03,,55.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.87,90,,62.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.82,32.15,,22.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.82,32.15,,22.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.14,88,,60.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.65,33.11,,22.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.82,77.87,
BLANKET FULL BODY,490010,CDM,270,RC,,,Outpatient,,,86.75,52.05,,73.74,85,,58.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.89,32.15,,22.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.43,80.03,,55.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.08,90,,62.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.89,32.15,,22.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.89,32.15,,22.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.34,88,,61.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.72,33.11,,22.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.89,78.08,
SEROTONIN LEVEL  (MAYO),1884261,CDM,300,RC,84260,HCPCS,Outpatient,,,86.75,52.05,,73.74,85,,58.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.43,80.03,,55.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,78.08,90,,62.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,38.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.34,88,,61.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.12,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,38.95,78.08,
O/T MMT - HAND,3171,CDM,430,RC,95832,HCPCS,Outpatient,,,86.75,52.05,,73.74,85,,58.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.89,32.15,,22.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.43,80.03,,55.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.08,90,,62.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.89,32.15,,22.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.89,32.15,,22.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.34,88,,61.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.72,33.11,,22.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.89,78.08,
CYANIDE BLOOD  (MAYO),1882600,CDM,300,RC,82600,HCPCS,Outpatient,,,87,52.2,,73.95,85,,59.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.63,80.03,,55.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,78.3,90,,62.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.56,88,,61.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.4,78.3,
MERCURY/CREATININE RATIO URINE  (MAYO),1883039,CDM,300,RC,83825,HCPCS,Outpatient,,,87,52.2,,73.95,85,,59.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.63,80.03,,55.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.58,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,78.3,90,,62.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.58,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.56,88,,61.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.45,78.3,
NEEDLE SPINAL WHITACRE 25GA X 5 TW,491664,CDM,270,RC,,,Outpatient,,,87.25,52.35,,74.16,85,,59.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.05,32.15,,22.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.83,80.03,,55.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.53,90,,62.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.05,32.15,,22.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.05,32.15,,22.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.78,88,,61.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.89,33.11,,23.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.05,78.53,
A procedure used to determine if fungi are present in an area of the body,1887106,CDM,300,RC,87101,HCPCS,Outpatient,,,87.25,52.35,,74.16,85,,59.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,69.83,80.03,,55.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,78.53,90,,62.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.78,88,,61.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.69,78.53,
ICU OBSERVATION,15007,CDM,762,RC,G0264,HCPCS,Outpatient,,,87.25,52.35,,74.16,85,,59.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.05,32.15,,22.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.83,80.03,,55.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.53,90,,62.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.05,32.15,,22.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.05,32.15,,22.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.78,88,,61.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.89,33.11,,23.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.05,78.53,
"ELECTROPHORETIC TECH, NES  (MAYO)",1883024,CDM,300,RC,82664,HCPCS,Outpatient,,,87.5,52.5,,74.38,85,,59.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.03,80.03,,56.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,62.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,78.75,90,,63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,62.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,43.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77,88,,61.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,43.2,78.75,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",3381,CDM,430,RC,97110,HCPCS,Outpatient,,,87.54,52.52,,74.41,85,,59.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.14,32.15,,22.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.06,80.03,,56.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,78.79,90,,63.03,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.14,32.15,,22.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,28.14,32.15,,22.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.04,88,,61.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.98,33.11,,23.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.14,78.79,
O/T SHOULDER IMMOBILIZER FAST WRAP,414,CDM,430,RC,L3660,HCPCS,Outpatient,,,87.7,52.62,,74.55,85,,59.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.2,32.15,,22.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.19,80.03,,56.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.93,90,,63.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.2,32.15,,22.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.2,32.15,,22.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.18,88,,61.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.04,33.11,,23.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.2,78.93,
FREE PHENYTOIN   (MAYO),1880186,CDM,300,RC,80186,HCPCS,Outpatient,,,87.75,52.65,,74.59,85,,59.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.23,80.03,,56.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.03,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,78.98,90,,63.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.03,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.22,88,,61.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.31,78.98,
..AMPHETAMINES CONFIRMATION  (MAYO),1882146,CDM,300,RC,80324,HCPCS,Outpatient,,,87.75,52.65,,74.59,85,,59.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.23,80.03,,56.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.98,90,,63.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.22,88,,61.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.55,78.98,
ISLET CELL AB  (MAYO),1886341,CDM,300,RC,86341,HCPCS,Outpatient,,,88,52.8,,74.8,85,,59.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.43,80.03,,56.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,79.2,90,,63.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.44,88,,61.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.89,79.2,
"CAR SEAT EVALUATION, NEONATE, 60 MIN",694780,CDM,460,RC,94780,HCPCS,Outpatient,,,88,52.8,,74.8,85,,59.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.43,80.03,,56.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,79.2,90,,63.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.44,88,,61.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.14,33.11,,23.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.29,79.2,
Blood test to evaluate thyroid function,1880070,CDM,300,RC,84439,HCPCS,Outpatient,,,88.36,53.02,,75.11,85,,60.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.71,80.03,,56.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,79.52,90,,63.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.76,88,,62.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.34,79.52,
PROCTOFOAM HC 15GM,298011,CDM,250,RC,,,Outpatient,,,88.39,53.03,,75.13,85,,60.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.42,32.15,,22.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.74,80.03,,56.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.55,90,,63.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.42,32.15,,22.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.39,,,,Other,Not Separately reimbursable,28.42,32.15,,22.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.78,88,,62.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.27,33.11,,23.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.42,79.55,
SET CYSTO,496478,CDM,270,RC,,,Outpatient,,,88.44,53.06,,75.17,85,,60.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.43,32.15,,22.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.78,80.03,,56.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.6,90,,63.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.43,32.15,,22.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.44,,,,Other,Not Separately reimbursable,28.43,32.15,,22.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.83,88,,62.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.28,33.11,,23.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.43,79.6,
HOLDER NEEDLE DISPOSABLE,49275,CDM,270,RC,,,Outpatient,,,88.5,53.1,,75.23,85,,60.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.83,80.03,,56.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.65,90,,63.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.5,,,,Other,Not Separately reimbursable,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.88,88,,62.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.3,33.11,,23.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.45,79.65,
ANOSCOPE LARGE SANI-SCOPE DISP,49307,CDM,270,RC,,,Outpatient,,,88.5,53.1,,75.23,85,,60.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.83,80.03,,56.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.65,90,,63.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.5,,,,Other,Not Separately reimbursable,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.88,88,,62.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.3,33.11,,23.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.45,79.65,
"DRAPE, T, LAPARO, TRANSVERSE 102X78X121",499281,CDM,270,RC,,,Outpatient,,,88.5,53.1,,75.23,85,,60.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.83,80.03,,56.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.65,90,,63.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.5,,,,Other,Not Separately reimbursable,28.45,32.15,,22.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.88,88,,62.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.3,33.11,,23.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.45,79.65,
"ASO TITER, STREPTOLYSIN O  (MAYO)",1886060,CDM,300,RC,86060,HCPCS,Outpatient,,,88.63,53.18,,75.34,85,,60.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.93,80.03,,56.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.44,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,79.77,90,,63.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.44,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.99,88,,62.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.05,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.79,79.77,
TRACHEOSTOMY TUBE,13070,CDM,270,RC,,,Outpatient,,,88.75,53.25,,75.44,85,,60.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.03,80.03,,56.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.88,90,,63.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.75,,,,Other,Not Separately reimbursable,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.1,88,,62.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.39,33.11,,23.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.53,79.88,
IMIPRAMINE & DESIPRAMINE  (MAYO),1883523,CDM,300,RC,80355,HCPCS,Outpatient,,,88.75,53.25,,75.44,85,,60.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.03,80.03,,56.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.88,90,,63.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.1,88,,62.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.39,33.11,,23.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.53,79.88,
ANTIBODY ELUTION (EACH),1887807,CDM,300,RC,86860,HCPCS,Outpatient,,,88.75,53.25,,75.44,85,,60.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.03,80.03,,56.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,79.88,90,,63.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.1,88,,62.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.12,79.88,
ANTIBODY NEUTRALIZATION,1887808,CDM,300,RC,86977,HCPCS,Outpatient,,,88.75,53.25,,75.44,85,,60.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.03,80.03,,56.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,79.88,90,,63.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,28.53,32.15,,22.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.1,88,,62.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.39,33.11,,23.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.53,79.88,
"BETA 2 GLYCOPROTEIN AB, IGG  (MAYO)",1882235,CDM,300,RC,86146,HCPCS,Outpatient,,,88.77,53.26,,75.45,85,,60.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.04,80.03,,56.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,79.89,90,,63.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.12,88,,62.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.99,79.89,
"BETA 2 GLYCOPROTEIN AB, IGM  (MAYO)",1882236,CDM,300,RC,86146,HCPCS,Outpatient,,,88.77,53.26,,75.45,85,,60.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.04,80.03,,56.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,79.89,90,,63.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.12,88,,62.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.99,79.89,
OXACILLIN : 2GM VIAL,293376,CDM,636,RC,J2700,HCPCS,Outpatient,,,88.84,53.3,,75.51,85,,60.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.1,80.03,,56.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.96,90,,63.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.18,88,,62.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.97,79.96,
Blood test to measure a type of estrogen in the blood,1882670,CDM,300,RC,82670,HCPCS,Outpatient,,,89,53.4,,75.65,85,,60.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.23,80.03,,56.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,80.1,90,,64.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,35.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.32,88,,62.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.19,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,35.14,80.1,
PROTEIN S ACTIVITY  (MAYO),1885309,CDM,300,RC,85306,HCPCS,Outpatient,,,89,53.4,,75.65,85,,60.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.23,80.03,,56.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,80.1,90,,64.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.32,88,,62.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.27,80.1,
ZOVIRAX (acyclovir) 500MG VIAL,293867,CDM,250,RC,,,Outpatient,,,89.2,53.52,,75.82,85,,60.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.68,32.15,,22.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.39,80.03,,57.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.28,90,,64.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.68,32.15,,22.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.68,32.15,,22.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.5,88,,62.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.53,33.11,,23.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.68,80.28,
HUMAN ALBUMIN 25%,2096391,CDM,636,RC,P9046,HCPCS,Outpatient,,,89.23,53.54,,75.85,85,,60.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.41,80.03,,57.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.65,102,,,fee schedule,Pays at 102% of CMS APC rate,80.31,90,,64.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,100,,,fee schedule,Pays at 100% of CMS APC rate,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.52,88,,62.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.23,80.31,
WOUND MANAGEMENT IV,3924,CDM,490,RC,11040,HCPCS,Outpatient,,,89.3,53.58,,75.91,85,,60.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.71,32.15,,22.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.47,80.03,,57.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.37,90,,64.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.71,32.15,,22.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.71,32.15,,22.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.58,88,,62.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.57,33.11,,23.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.71,80.37,
RELENZA 5MG/INH INHALER #5,293509,CDM,250,RC,,,Outpatient,,,89.5,53.7,,76.08,85,,60.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.77,32.15,,23.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.63,80.03,,57.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.55,90,,64.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.77,32.15,,23.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.77,32.15,,23.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.76,88,,63.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.63,33.11,,23.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.77,80.55,
MONISTAT 200MG (miconazole) VAG SUPP #3,291067,CDM,250,RC,,,Outpatient,,,89.6,53.76,,76.16,85,,60.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.81,32.15,,23.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.71,80.03,,57.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.64,90,,64.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.81,32.15,,23.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.81,32.15,,23.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.85,88,,63.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.67,33.11,,23.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.81,80.64,
BRIEFS ADULT MEDIUM,49029,CDM,270,RC,,,Outpatient,,,89.69,53.81,,76.24,85,,60.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.84,32.15,,23.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.78,80.03,,57.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.72,90,,64.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.84,32.15,,23.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.84,32.15,,23.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.93,88,,63.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.7,33.11,,23.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.84,80.72,
BRIEFS ADULT LARGE,49037,CDM,270,RC,,,Outpatient,,,89.69,53.81,,76.24,85,,60.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.84,32.15,,23.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.78,80.03,,57.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.72,90,,64.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.84,32.15,,23.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.84,32.15,,23.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.93,88,,63.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.7,33.11,,23.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.84,80.72,
CATHETER FOLEY 20FR 30C WHISTLE TIP 3WAY,49410,CDM,270,RC,,,Outpatient,,,89.75,53.85,,76.29,85,,61.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.85,32.15,,23.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.83,80.03,,57.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.78,90,,64.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.85,32.15,,23.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.85,32.15,,23.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.98,88,,63.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.72,33.11,,23.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.85,80.78,
CATHETER FOLEY 22FR 30C WHISTLE TIP 3WAY,49418,CDM,270,RC,,,Outpatient,,,89.75,53.85,,76.29,85,,61.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.85,32.15,,23.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.83,80.03,,57.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.78,90,,64.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.85,32.15,,23.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.85,32.15,,23.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.98,88,,63.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.72,33.11,,23.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.85,80.78,
"REPTILASE, PLASMA  (MAYO)",1885216,CDM,300,RC,85635,HCPCS,Outpatient,,,89.75,53.85,,76.29,85,,61.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.83,80.03,,57.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,80.78,90,,64.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.98,88,,63.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.38,80.78,
NASACORT INHALER,292056,CDM,250,RC,,,Outpatient,,,89.87,53.92,,76.39,85,,61.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.89,32.15,,23.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.92,80.03,,57.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.88,90,,64.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.89,32.15,,23.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.89,32.15,,23.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.09,88,,63.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.76,33.11,,23.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.89,80.88,
SODIUM PHOSPHATE: 45MMOL INJ/15ML,293165,CDM,250,RC,,,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
BIAXIN (clarithrom)125MG/5ML SUSP: 50ML,294073,CDM,250,RC,,,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
BRACE ISLO,49500,CDM,270,RC,,,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
DERMATOME,96240,CDM,270,RC,,,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
NEEDLE JAMSHIDI DISPOSABLE,491534,CDM,270,RC,,,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
SCALE SPRING OHAUS 5000MS,4980075,CDM,270,RC,,,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
...BILIRUBIN  NEWBORN,1882240,CDM,300,RC,82247,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,81,
"SEROTONIN, 5-HIAA  RANDOM  (MAYO)",1884259,CDM,300,RC,83497,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.21,81,
"Blood test, clotting time",1885205,CDM,300,RC,85610,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.37,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.37,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.94,81,
Coagulation assessment blood test,1885734,CDM,300,RC,85730,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.54,81,
"CULTURE FUNGI OTHER, NOT BLOOD  (MAYO)",1887108,CDM,300,RC,87102,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.89,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.57,81,
A type of physical therapy,348,CDM,420,RC,97116,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
A technique used by physical therapists to restore normal body movement patterns,311104,CDM,420,RC,97112,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
P/T WHIRLPOOL,311201,CDM,420,RC,97022,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
FEEDING/DYSPHAGIA EV(INACTIVE),31135,CDM,440,RC,92502,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,437.94,102,,,fee schedule,Pays at 102% of CMS APC rate,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.94,100,,,fee schedule,Pays at 100% of CMS APC rate,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
NM THALLIUM,23068,CDM,636,RC,A9505,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
LABOR ROOM PRECIPITATION,6001,CDM,721,RC,,,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
RECTAL TEMPERATURE CABLE,16030,CDM,732,RC,93012,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
ANTI-DNase B TITER  (MAYO),1884888,CDM,300,RC,82615,HCPCS,Outpatient,,,90.09,54.05,,76.58,85,,61.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.1,80.03,,57.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81.08,90,,64.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.28,88,,63.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.27,81.08,
DIFLUCAN (fluconazole) SUSP 10MG/ML:35ML,292225,CDM,250,RC,,,Outpatient,,,90.35,54.21,,76.8,85,,61.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.05,32.15,,23.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.31,80.03,,57.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.32,90,,65.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.05,32.15,,23.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.05,32.15,,23.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.51,88,,63.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.91,33.11,,23.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.05,81.32,
CEFOTAN (CEFOTETAN) : 2GM PB,293310,CDM,250,RC,S0074,HCPCS,Outpatient,,,90.39,54.23,,76.83,85,,61.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.34,80.03,,57.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.35,90,,65.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.54,88,,63.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.35,
O/T BRACE/ORTHOTICS FIT/ADJUSTMENT II,360,CDM,430,RC,97504,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
HAND SPLINT FIT/CONSTRUCTION II,388,CDM,430,RC,97504,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
"O/T EVALUATION, BASIC",593001,CDM,430,RC,97750,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
Occupational therapy,593008,CDM,430,RC,97535,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",593011,CDM,430,RC,97110,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
A technique used by physical therapists to restore normal body movement patterns,593024,CDM,430,RC,97112,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
O/T SPLINT ADJUSTMENT,593031,CDM,430,RC,97504,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
MINI WHIRLPOOL,593034,CDM,430,RC,97022,HCPCS,Outpatient,,,90.4,54.24,,76.84,85,,61.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.35,80.03,,57.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.36,90,,65.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.06,32.15,,23.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,88,,63.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.93,33.11,,23.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.06,81.36,
RESP THERAPY CONSULT,30125,CDM,270,RC,,,Outpatient,,,90.5,54.3,,76.93,85,,61.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.43,80.03,,57.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.45,90,,65.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.64,88,,63.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.96,33.11,,23.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.1,81.45,
.CROUP TENT,30170,CDM,270,RC,,,Outpatient,,,90.5,54.3,,76.93,85,,61.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.43,80.03,,57.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.45,90,,65.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.64,88,,63.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.96,33.11,,23.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.1,81.45,
CATH FOLEY 22FR 30ML 3-WAY,49529,CDM,270,RC,,,Outpatient,,,90.5,54.3,,76.93,85,,61.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.43,80.03,,57.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.45,90,,65.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.64,88,,63.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.96,33.11,,23.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.1,81.45,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",22156,CDM,403,RC,77066,HCPCS,Outpatient,,,90.5,54.3,,76.93,85,,61.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.43,80.03,,57.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,92.31,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.45,90,,65.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.31,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.64,88,,63.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.96,33.11,,23.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.1,81.45,
MM MAMMO UNILAT EMPLOYEE RT,22296,CDM,403,RC,77056,HCPCS,Outpatient,,,90.5,54.3,,76.93,85,,61.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.43,80.03,,57.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.45,90,,65.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.64,88,,63.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.96,33.11,,23.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.1,81.45,
O/T PHYSICAL PERFORMANCE TEST,5997750,CDM,430,RC,97750,HCPCS,Outpatient,,,90.5,54.3,,76.93,85,,61.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.43,80.03,,57.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.45,90,,65.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.1,32.15,,23.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.64,88,,63.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.96,33.11,,23.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.1,81.45,
FIBRINOGEN  (MAYO),1885201,CDM,300,RC,85384,HCPCS,Outpatient,,,90.75,54.45,,77.14,85,,61.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.63,80.03,,58.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.91,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81.68,90,,65.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.91,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.86,88,,63.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.68,81.68,
"WEST NILE RNA-PCR, CSF  (MAYO)",1886792,CDM,300,RC,87798,HCPCS,Outpatient,,,90.75,54.45,,77.14,85,,61.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.63,80.03,,58.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81.68,90,,65.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.86,88,,63.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,81.68,
FLONASE (fluticasone) NASAL SPRAY,292059,CDM,250,RC,,,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
BASIC DOSE KIT,2932294,CDM,250,RC,,,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
"ORGANIC ACID SCREEN, URINE  (MAYO)",1882110,CDM,300,RC,83919,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.7,81.9,
Manipulation of 1 or more regions of the body,353,CDM,420,RC,97140,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
P/T SENSORY INTEGRATION,3973,CDM,420,RC,97533,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,59.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
P/T PROSTHETIC INITIAL ENCOUNTER,31126,CDM,420,RC,97761,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.16,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.16,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
Manipulation of 1 or more regions of the body,3197750,CDM,420,RC,97140,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
"P/T ORTHOTIC, INITIAL, EA 15 MIN",3197760,CDM,420,RC,97760,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,46.26,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.26,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
"P/T PROSTHETIC, INITIAL, EA 15 MIN",3197761,CDM,420,RC,97761,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.16,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.16,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
P/T MMT - EXTREMITY AND TRUNK (NO HAND),316,CDM,424,RC,95831,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
P/T MMT - HAND,317,CDM,424,RC,95832,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
O/T MMT- EXTREMITY AND TRUNK (NO HAND),3161,CDM,430,RC,95831,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
Manipulation of 1 or more regions of the body,3531,CDM,430,RC,97140,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
Manipulation of 1 or more regions of the body,3571,CDM,430,RC,97140,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
O/T SENSORY INTEGRATION,3962,CDM,430,RC,97533,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,59.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
O/T KINESIO TAPING,599733,CDM,430,RC,97533,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,59.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
O/T COGNITIVE RETRAINING,3197127,CDM,430,RC,97127,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
O/T COGNITIVE RETRAINING EA 15 MIN,3200515,CDM,430,RC,G0515,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
O/T COGNITIVE RETRAINING INITIAL 15 MIN,5997129,CDM,430,RC,97129,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.2,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.2,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
O/T COGNITIVE RETRAINING EACH ADD 15 MIN,5997130,CDM,430,RC,97130,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.5,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.5,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
"S/T SENSORY INTEGRATION, EA 15 MINUTES",322024,CDM,440,RC,97533,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,59.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
S/T COGNITIVE RETRAINING INITIAL 15 MIN,3297129,CDM,440,RC,97129,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.2,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22.2,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
S/T COGNITIVE RETRAINING EACH ADD 15 MIN,3297130,CDM,440,RC,97130,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.5,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.5,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
YEAST/FUNGUS ID  (MAYO),1887104,CDM,300,RC,87106,HCPCS,Outpatient,,,91.25,54.75,,77.56,85,,62.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.03,80.03,,58.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,82.13,90,,65.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.3,88,,64.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,82.13,
Blood test to screen for syphilis,1886590,CDM,300,RC,86592,HCPCS,Outpatient,,,91.5,54.9,,77.78,85,,62.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.23,80.03,,58.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,82.35,90,,65.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.52,88,,64.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.65,82.35,
C. DIFF BY PCR,1887231,CDM,300,RC,87493,HCPCS,Outpatient,,,91.64,54.98,,77.89,85,,62.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.46,32.15,,23.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.34,80.03,,58.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,38.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,82.48,90,,65.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.46,32.15,,23.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,29.46,32.15,,23.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.64,88,,64.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.34,33.11,,24.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.46,82.48,
PM-SCL AB  (MAYO),1886340,CDM,300,RC,86235,HCPCS,Outpatient,,,92.25,55.35,,78.41,85,,62.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.83,80.03,,59.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,83.03,90,,66.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.18,88,,64.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,83.03,
MEFOXIN (cefoxitin)  2GM /NS 100ML PB,293110,CDM,636,RC,J0694,HCPCS,Outpatient,,,92.4,55.44,,78.54,85,,62.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,73.95,80.03,,59.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.16,90,,66.53,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,5.17,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.31,88,,65.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.17,83.16,
CATH THORACIC 32FR STRAIGHT 20,49602,CDM,270,RC,,,Outpatient,,,92.5,55.5,,78.63,85,,62.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.74,32.15,,23.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.03,80.03,,59.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.25,90,,66.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.74,32.15,,23.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.74,32.15,,23.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.4,88,,65.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.63,33.11,,24.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.74,83.25,
CALCULI ANALYSIS & GROSS (LOUIS HERRING),2182355,CDM,300,RC,82360,HCPCS,Outpatient,,,92.5,55.5,,78.63,85,,62.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.03,80.03,,59.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,83.25,90,,66.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.4,88,,65.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,83.25,
RBC TREATMENT (TBC),1887814,CDM,300,RC,86970,HCPCS,Outpatient,,,92.75,55.65,,78.84,85,,63.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.82,32.15,,23.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.23,80.03,,59.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,83.48,90,,66.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.82,32.15,,23.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,29.82,32.15,,23.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.62,88,,65.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.71,33.11,,24.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.82,83.48,
"COPPER, URINE 24 HOUR (MAYO)",1882526,CDM,300,RC,82525,HCPCS,Outpatient,,,92.79,55.67,,78.87,85,,63.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.26,80.03,,59.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,83.51,90,,66.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.66,88,,65.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.61,83.51,
W/C MOBILITY,371,CDM,420,RC,97542,HCPCS,Outpatient,,,92.81,55.69,,78.89,85,,63.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.84,32.15,,23.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.28,80.03,,59.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.95,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,83.53,90,,66.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.84,32.15,,23.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.95,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.84,32.15,,23.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.67,88,,65.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.73,33.11,,24.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.84,83.53,
CEFZIL (cefprozil) 250MG/5ML SUSP: 100ML,29913,CDM,250,RC,,,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
ISUPREL (isoproterenol) 0.2MG/ML INJ,293240,CDM,250,RC,,,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
EYE PACK-HARRIS,296400,CDM,250,RC,,,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
LOTRISONE CRM (BETAMETHASONE/CLOTRIM)45G,298059,CDM,250,RC,,,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
BED GO II,49080,CDM,270,RC,,,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
DHE-45  (dihydroergotamine) : 1MG AMP,293259,CDM,636,RC,J1110,HCPCS,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,46.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,46.52,83.7,
PCA FENTANYL 1000mcg/50ml NS,299077,CDM,636,RC,J3010,HCPCS,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.85,83.7,
Outpatient visit of established patient not requiring a physician,4004,CDM,760,RC,99211,HCPCS,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
Outpatient visit of established patient not requiring a physician,5004,CDM,760,RC,99211,HCPCS,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
Outpatient visit of established patient not requiring a physician,6011,CDM,760,RC,99211,HCPCS,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
Outpatient visit of established patient not requiring a physician,15005,CDM,760,RC,99211,HCPCS,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
Outpatient visit of established patient not requiring a physician,3004,CDM,762,RC,99211,HCPCS,Outpatient,,,93,55.8,,79.05,85,,63.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.43,80.03,,59.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.7,90,,66.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.9,32.15,,23.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.84,88,,65.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.79,33.11,,24.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.9,83.7,
DRUG SCREENING OXYCODONE  (MAYO),1882791,CDM,300,RC,80365,HCPCS,Outpatient,,,93.02,55.81,,79.07,85,,63.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.91,32.15,,23.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.44,80.03,,59.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.72,90,,66.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.91,32.15,,23.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.91,32.15,,23.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.86,88,,65.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.8,33.11,,24.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.91,83.72,
EPOGEN (EPOETIN)*DIALYSIS: 2000 UNIT INJ,293448,CDM,636,RC,Q4081,HCPCS,Outpatient,,,93.03,55.82,,79.08,85,,63.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.45,80.03,,59.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.73,90,,66.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.87,88,,65.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.71,83.73,
EPOGEN *NON DIALYSIS*:2000UNITS INJ,293561,CDM,636,RC,J0885,HCPCS,Outpatient,,,93.03,55.82,,79.08,85,,63.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.45,80.03,,59.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.23,102,,,fee schedule,Pays at 102% of CMS APC rate,83.73,90,,66.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.23,100,,,fee schedule,Pays at 100% of CMS APC rate,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.87,88,,65.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.09,83.73,
.MANUAL RESUSCITATOR DISPOSIBLE,30355,CDM,270,RC,,,Outpatient,,,93.07,55.84,,79.11,85,,63.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.92,32.15,,23.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.48,80.03,,59.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.76,90,,67.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.92,32.15,,23.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.92,32.15,,23.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.9,88,,65.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.82,33.11,,24.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.92,83.76,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",327,CDM,420,RC,97016,HCPCS,Outpatient,,,93.15,55.89,,79.18,85,,63.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.95,32.15,,23.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.55,80.03,,59.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.44,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,83.84,90,,67.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.95,32.15,,23.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.95,32.15,,23.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.97,88,,65.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.84,33.11,,24.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.95,83.84,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",3271,CDM,430,RC,97016,HCPCS,Outpatient,,,93.15,55.89,,79.18,85,,63.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.95,32.15,,23.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.55,80.03,,59.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.44,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,83.84,90,,67.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.95,32.15,,23.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.44,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,29.95,32.15,,23.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.97,88,,65.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.84,33.11,,24.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.95,83.84,
BRACE CLAVICAL MEDIUM,491172,CDM,270,RC,,,Outpatient,,,93.25,55.95,,79.26,85,,63.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.98,32.15,,23.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.63,80.03,,59.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.93,90,,67.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.98,32.15,,23.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.98,32.15,,23.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.06,88,,65.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.88,33.11,,24.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.98,83.93,
PROCAINAMIDE LEVEL  (MAYO),1884142,CDM,300,RC,80192,HCPCS,Outpatient,,,93.25,55.95,,79.26,85,,63.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.63,80.03,,59.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,83.93,90,,67.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.07,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.06,88,,65.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.07,83.93,
VARICELLA ZOSTER (PCR)  (MAYO),1887796,CDM,300,RC,87798,HCPCS,Outpatient,,,93.25,55.95,,79.26,85,,63.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.63,80.03,,59.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,83.93,90,,67.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.06,88,,65.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,83.93,
LOVENOX (enoxaparin) : 80MG INJ,293444,CDM,250,RC,,,Outpatient,,,93.27,55.96,,79.28,85,,63.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.99,32.15,,23.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.64,80.03,,59.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.94,90,,67.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.99,32.15,,23.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.99,32.15,,23.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.08,88,,65.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.88,33.11,,24.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.99,83.94,
TRANEXAMIC ACID 1GM VIAL,293017,CDM,250,RC,,,Outpatient,,,93.33,56,,79.33,85,,63.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.01,32.15,,24.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.69,80.03,,59.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84,90,,67.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.01,32.15,,24.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.01,32.15,,24.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.13,88,,65.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.9,33.11,,24.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.01,84,
Repeated application to one or more parts of the body,322030,CDM,440,RC,97032,HCPCS,Outpatient,,,93.5,56.1,,79.48,85,,63.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.06,32.15,,24.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.83,80.03,,59.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,84.15,90,,67.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.06,32.15,,24.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,30.06,32.15,,24.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.28,88,,65.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.96,33.11,,24.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.06,84.15,
CIRCUIT ANESTHESIA ADULT WITH SZ5 MASK,490042,CDM,270,RC,,,Outpatient,,,93.75,56.25,,79.69,85,,63.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.03,80.03,,60.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.38,90,,67.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.5,88,,66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.04,33.11,,24.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.14,84.38,
LDL CHOLESTEROL DIRECT (MAYO),1883717,CDM,300,RC,83721,HCPCS,Outpatient,,,93.75,56.25,,79.69,85,,63.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.03,80.03,,60.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.71,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,84.38,90,,67.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.71,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.5,88,,66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.36,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12,84.38,
NM MDP,2932285,CDM,343,RC,A9503,HCPCS,Outpatient,,,93.75,56.25,,79.69,85,,63.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.03,80.03,,60.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.38,90,,67.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.5,88,,66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.04,33.11,,24.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.14,84.38,
MM ADD ON 3D  DIAG DIG TOM UNI/BIL,2200279,CDM,401,RC,G0279,HCPCS,Outpatient,,,93.75,56.25,,79.69,85,,63.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.03,80.03,,60.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.92,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,84.38,90,,67.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.92,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,30.14,32.15,,24.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.5,88,,66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.04,33.11,,24.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.14,84.38,
"LACTATE, BODY FLUID  (MAYO)",1886757,CDM,300,RC,83605,HCPCS,Outpatient,,,94,56.4,,79.9,85,,63.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.23,80.03,,60.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.8,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,84.6,90,,67.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.8,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.72,88,,66.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.43,84.6,
AUGMENTIN (AMOX/CLAV) 125MG/5ML: 150ML,294057,CDM,250,RC,,,Outpatient,,,94.25,56.55,,80.11,85,,64.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.43,80.03,,60.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.83,90,,67.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.94,88,,66.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.21,33.11,,24.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.3,84.83,
TUBE ENDOTROL 8 MM ENDOTRACH,493771,CDM,270,RC,,,Outpatient,,,94.25,56.55,,80.11,85,,64.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.43,80.03,,60.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.83,90,,67.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.94,88,,66.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.21,33.11,,24.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.3,84.83,
TUBE ENDOTROL 7 MM ENDOTRACH,493772,CDM,270,RC,,,Outpatient,,,94.25,56.55,,80.11,85,,64.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.43,80.03,,60.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.83,90,,67.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.3,32.15,,24.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.94,88,,66.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.21,33.11,,24.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.3,84.83,
Blood test to monitor vitamin D levels,1882306,CDM,300,RC,82306,HCPCS,Outpatient,,,94.25,56.55,,80.11,85,,64.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.22,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.43,80.03,,60.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.19,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,84.83,90,,67.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.22,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.19,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,37.22,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.94,88,,66.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.34,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.22,84.83,
"ID MALDI-TOF, ANAEROBE  (MAYO)",1884892,CDM,300,RC,87076,HCPCS,Outpatient,,,94.25,56.55,,80.11,85,,64.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.43,80.03,,60.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,84.83,90,,67.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.94,88,,66.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.16,84.83,
"CULTURE, STOOL",1887045,CDM,300,RC,87045,HCPCS,Outpatient,,,94.3,56.58,,80.16,85,,64.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.32,32.15,,24.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.47,80.03,,60.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,84.87,90,,67.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.32,32.15,,24.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.32,32.15,,24.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.98,88,,66.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.22,33.11,,24.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.32,84.87,
THROMBOSTAT (bovine topical thrombin) 5K,296061,CDM,250,RC,,,Outpatient,,,94.35,56.61,,80.2,85,,64.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.33,32.15,,24.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.51,80.03,,60.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.92,90,,67.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.33,32.15,,24.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.33,32.15,,24.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.03,88,,66.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.24,33.11,,24.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.33,84.92,
PERSANTINE (dipyridamole)5MG/ML:2ML AMP,293396,CDM,250,RC,J1245,HCPCS,Outpatient,,,94.5,56.7,,80.33,85,,64.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.63,80.03,,60.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.05,90,,68.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,83.16,88,,66.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.69,85.05,
FEEDER FINGER HAZELBAKER,499613,CDM,270,RC,,,Outpatient,,,94.5,56.7,,80.33,85,,64.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.38,32.15,,24.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.63,80.03,,60.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.05,90,,68.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.38,32.15,,24.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.38,32.15,,24.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.16,88,,66.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.29,33.11,,25.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.38,85.05,
CONGENITAL ADRENAL HYPERPLASIA  (MAYO),1883499,CDM,300,RC,,,Outpatient,,,94.5,56.7,,80.33,85,,64.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.38,32.15,,24.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.63,80.03,,60.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.05,90,,68.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.38,32.15,,24.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.38,32.15,,24.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.16,88,,66.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.29,33.11,,25.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.38,85.05,
HIV-2 CONFIRMATION  (MAYO),1886311,CDM,300,RC,86689,HCPCS,Outpatient,,,94.5,56.7,,80.33,85,,64.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.63,80.03,,60.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,85.05,90,,68.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,83.16,88,,66.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.12,85.05,
BRIEFS ADULT XXLARGE,49038,CDM,270,RC,,,Outpatient,,,94.69,56.81,,80.49,85,,64.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.44,32.15,,24.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.78,80.03,,60.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.22,90,,68.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.44,32.15,,24.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.44,32.15,,24.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.33,88,,66.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.35,33.11,,25.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.44,85.22,
OP OBSERVATION,3003,CDM,762,RC,99218,HCPCS,Outpatient,,,94.71,56.83,,80.5,85,,64.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.45,32.15,,24.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.8,80.03,,60.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.24,90,,68.19,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.45,32.15,,24.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.45,32.15,,24.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.34,88,,66.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.36,33.11,,25.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.45,85.24,
AZACTAM (aztreonam) : 1GM VIAL,293347,CDM,250,RC,S0073,HCPCS,Outpatient,,,94.8,56.88,,80.58,85,,64.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.48,32.15,,24.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.87,80.03,,60.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.32,90,,68.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.48,32.15,,24.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.48,32.15,,24.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.42,88,,66.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.39,33.11,,25.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.48,85.32,
IV THERAPY HYDRATION ADDITIONAL HOUR,290084,CDM,260,RC,96361,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
"ACID HEMOLYSIN TEST, HAM'S  (MAYO)",1886281,CDM,300,RC,85475,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.55,85.5,
Manipulation of 1 or more regions of the body,355,CDM,420,RC,97140,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
W/C MOBILITY III,373,CDM,420,RC,97542,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.95,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.95,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
INPATIENT TRACTION ASSEMBLY III,384,CDM,420,RC,97139,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
Occupational therapy,367,CDM,430,RC,97535,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
O/T COGNITIVE RETRAININING III,377,CDM,430,RC,97770,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
O/T COGNITIVE RETRAINING IV,378,CDM,430,RC,97770,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
O/T MYOFASCIAL RELEASE III,3551,CDM,430,RC,97250,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
DO NOT USE,3195900,CDM,922,RC,95904,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
SEREVENT DISKUS 50MCG *HOSP PAK *#28,292122,CDM,636,RC,J3535,HCPCS,Outpatient,,,95.5,57.3,,81.18,85,,64.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.7,32.15,,24.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.43,80.03,,61.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.95,90,,68.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.7,32.15,,24.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.7,32.15,,24.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.04,88,,67.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.62,33.11,,25.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.7,85.95,
CECLOR (CEFACLOR) 250MG/5ML SUSP: 150ML,294010,CDM,250,RC,,,Outpatient,,,95.54,57.32,,81.21,85,,64.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.72,32.15,,24.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.46,80.03,,61.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.99,90,,68.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.72,32.15,,24.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.72,32.15,,24.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.08,88,,67.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.63,33.11,,25.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.72,85.99,
VASOACTIVE INTEST. POLYPEPTIDE  (MAYO),1884586,CDM,300,RC,84586,HCPCS,Outpatient,,,95.75,57.45,,81.39,85,,65.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.63,80.03,,61.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,36.03,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.18,90,,68.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.03,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,44.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.26,88,,67.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.43,86.18,
PHOSPHATIDYLGLYCEROL  (MAYO),1883662,CDM,300,RC,84081,HCPCS,Outpatient,,,96,57.6,,81.6,85,,65.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,76.83,80.03,,61.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.4,90,,69.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.48,88,,67.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.4,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.78,86.4,
NASACORT AQ NASAL INHALER,292084,CDM,250,RC,,,Outpatient,,,96.05,57.63,,81.64,85,,65.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.88,32.15,,24.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.87,80.03,,61.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.45,90,,69.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.88,32.15,,24.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.88,32.15,,24.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.52,88,,67.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.8,33.11,,25.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.88,86.45,
AUGMENTIN (AMOX/CLAV) 200MG/5ML : 100ML,294076,CDM,250,RC,,,Outpatient,,,96.05,57.63,,81.64,85,,65.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.88,32.15,,24.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.87,80.03,,61.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.45,90,,69.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.88,32.15,,24.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.88,32.15,,24.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.52,88,,67.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.8,33.11,,25.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.88,86.45,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",6016,CDM,260,RC,96375,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.87,33.11,,25.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.94,86.63,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",11017,CDM,260,RC,96375,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.87,33.11,,25.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.94,86.63,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",1490781,CDM,260,RC,96375,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.87,33.11,,25.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.94,86.63,
HGB ELECTROPHORESIS BLOOD  (MAYO),1883022,CDM,300,RC,83020,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.29,86.63,
PT MIXING STUDY  (MAYO),1885736,CDM,300,RC,85611,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.96,86.63,
STREPTOCOCCUS PNEUMONIAE AG URIN  (MAYO),1886403,CDM,300,RC,87899,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,86.63,
"BORDETELLA PERTUSSIS, IGG  (MAYO)",1886614,CDM,300,RC,86615,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.59,86.63,
A procedure used to determine if fungi are present in an area of the body,1887102,CDM,300,RC,87101,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.69,86.63,
CULTURE AFB  (MAYO),1887117,CDM,300,RC,87116,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.87,33.11,,25.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.94,86.63,
Multiple allergy shots,11025,CDM,940,RC,95117,HCPCS,Outpatient,,,96.25,57.75,,81.81,85,,65.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.03,80.03,,61.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,86.63,90,,69.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,30.94,32.15,,24.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.7,88,,67.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.87,33.11,,25.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.94,86.63,
Blood test to diagnose rheumatoid arthritis,1886200,CDM,300,RC,86200,HCPCS,Outpatient,,,96.45,57.87,,81.98,85,,65.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.19,80.03,,61.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,86.81,90,,69.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.88,88,,67.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,86.81,
HOUSEHOLD LOOP SCISSORS,440,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
BURN PACK (STERILE),49007,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
SUCTION GOMCO,49030,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
CATH THORACIC 36FR STRAIGHT 20,49906,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
CATH THORACIC 28FR STRAIGHT,49912,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
DISSECTOR KITTNER,493052,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
PASTE STOMAHESIVE 2OZ TUBE,493202,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
CONNECTOR UNIVERSAL SAFE-LOCK,493469,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
SET NITRO GLYCERIN,496500,CDM,270,RC,,,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
Repeated application to one or more parts of the body,326,CDM,420,RC,97032,HCPCS,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
"P/T CONTRAST BATH, EACH AREA",334,CDM,420,RC,97034,HCPCS,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
Repeated application to one or more parts of the body,3197032,CDM,420,RC,97032,HCPCS,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
"O/T CONTRAST BATH, EACH AREA",3341,CDM,430,RC,97034,HCPCS,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
O/T CUSTOM ULNAR GUTTER SPLINT,3944,CDM,430,RC,L3906,HCPCS,Outpatient,,,96.5,57.9,,82.03,85,,65.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.23,80.03,,61.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,69.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.02,32.15,,24.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.92,88,,67.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.95,33.11,,25.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.02,86.85,
ELECTRO LUBE,499994,CDM,270,RC,,,Outpatient,,,96.75,58.05,,82.24,85,,65.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.11,32.15,,24.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.43,80.03,,61.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.08,90,,69.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.11,32.15,,24.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.75,,,,Other,Not Separately reimbursable,31.11,32.15,,24.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.14,88,,68.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.03,33.11,,25.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.11,87.08,
MAXIPIME (CEFEPIME) : 2GM VIAL,293876,CDM,636,RC,J0692,HCPCS,Outpatient,,,96.86,58.12,,82.33,85,,65.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.14,32.15,,24.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.52,80.03,,62.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.17,90,,69.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.14,32.15,,24.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.86,,,,Other,Not Separately reimbursable,31.14,32.15,,24.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.24,88,,68.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.07,33.11,,25.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.14,87.17,
OMNICEF (cefdinir) 125MG/5ML SUSP 60ML,295195,CDM,250,RC,,,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97,,,,Other,Not Separately reimbursable,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.12,33.11,,25.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.19,87.3,
SET EPIDURAL PUMP,49378,CDM,270,RC,,,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97,,,,Other,Not Separately reimbursable,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.12,33.11,,25.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.19,87.3,
TUBE LAVAGE LAVACUATOR 36FR,491858,CDM,270,RC,,,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97,,,,Other,Not Separately reimbursable,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.12,33.11,,25.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.19,87.3,
"GALACTOSE-ALPHA-1,3-GALACTOSE  (MAYO)",1884828,CDM,300,RC,86008,HCPCS,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.71,87.3,
HYPERSENSITIVE PNUEMONITIS IGG  (MAYO),1886672,CDM,300,RC,86606,HCPCS,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.93,87.3,
ANTIBODY PANEL (TBC),1887809,CDM,300,RC,86870,HCPCS,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.12,87.3,
BP MONITOR,14253,CDM,450,RC,,,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97,,,,Other,Not Separately reimbursable,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.12,33.11,,25.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.19,87.3,
CLEAN/DEBR/C ANES SMALL,1416010,CDM,450,RC,16010,HCPCS,Outpatient,,,97,58.2,,82.45,85,,65.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.63,80.03,,62.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.3,90,,69.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97,,,,Other,Not Separately reimbursable,31.19,32.15,,24.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.36,88,,68.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.12,33.11,,25.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.19,87.3,
MM 3D MAMMO SCREENING BILAT,77063,CDM,403,RC,77063,HCPCS,Outpatient,,,97.19,58.31,,82.61,85,,66.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.25,32.15,,25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.78,80.03,,62.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.92,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,87.47,90,,69.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.25,32.15,,25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,21.92,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.25,32.15,,25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.53,88,,68.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.18,33.11,,25.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.25,87.47,
PRIMAXIN (imipenem) 500MG / NS 100ML PB,293329,CDM,636,RC,J0743,HCPCS,Outpatient,,,97.2,58.32,,82.62,85,,66.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.79,80.03,,62.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.48,90,,69.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.2,,,,Other,Not Separately reimbursable,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.54,88,,68.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.93,87.48,
DRESSING VAC GRANUFOAM SMALL,49687,CDM,270,RC,,,Outpatient,,,97.22,58.33,,82.64,85,,66.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.26,32.15,,25.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.81,80.03,,62.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.5,90,,70,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.26,32.15,,25.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.22,,,,Other,Not Separately reimbursable,31.26,32.15,,25.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.55,88,,68.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.19,33.11,,25.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.26,87.5,
"IMMUNHISTOCHEM STAIN, ADDL  (CSI)",2188335,CDM,310,RC,88341,HCPCS,Outpatient,,,97.25,58.35,,82.66,85,,66.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.83,80.03,,62.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.53,90,,70.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.25,,,,Other,Not Separately reimbursable,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.58,88,,68.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,57.38,87.53,
"IMMUNHISTOCHEM STAIN, ADDL  (IGO)",2188337,CDM,310,RC,88341,HCPCS,Outpatient,,,97.25,58.35,,82.66,85,,66.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,77.83,80.03,,62.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.53,90,,70.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.25,,,,Other,Not Separately reimbursable,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.58,88,,68.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,57.38,87.53,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",22121,CDM,401,RC,77066,HCPCS,Outpatient,,,97.25,58.35,,82.66,85,,66.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.83,80.03,,62.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,99.2,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,87.53,90,,70.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.2,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.58,88,,68.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.2,33.11,,25.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.27,87.53,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",22126,CDM,401,RC,77066,HCPCS,Outpatient,,,97.25,58.35,,82.66,85,,66.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.83,80.03,,62.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,99.2,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,87.53,90,,70.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.2,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.58,88,,68.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.2,33.11,,25.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.27,87.53,
MM MAMMO DIAG UNILAT RT,22294,CDM,401,RC,77056,HCPCS,Outpatient,,,97.25,58.35,,82.66,85,,66.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.83,80.03,,62.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.53,90,,70.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.25,,,,Other,Not Separately reimbursable,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.58,88,,68.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.2,33.11,,25.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.27,87.53,
MM MAMMO SPOT COMPR UNILAT RT,22295,CDM,401,RC,77056,HCPCS,Outpatient,,,97.25,58.35,,82.66,85,,66.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.83,80.03,,62.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.53,90,,70.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.25,,,,Other,Not Separately reimbursable,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.58,88,,68.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.2,33.11,,25.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.27,87.53,
Manipulation of 1 or more regions of the body,357,CDM,420,RC,97140,HCPCS,Outpatient,,,97.25,58.35,,82.66,85,,66.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.83,80.03,,62.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,87.53,90,,70.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.27,32.15,,25.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.58,88,,68.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.2,33.11,,25.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.27,87.53,
TUBE TRACH UNCUFFED SIZE 8.0,493850,CDM,270,RC,,,Outpatient,,,97.5,58.5,,82.88,85,,66.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.35,32.15,,25.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.03,80.03,,62.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.75,90,,70.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.35,32.15,,25.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.5,,,,Other,Not Separately reimbursable,31.35,32.15,,25.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.8,88,,68.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.28,33.11,,25.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.35,87.75,
Detection test for human papillomavirus (hpv),2188143,CDM,300,RC,87624,HCPCS,Outpatient,,,97.5,58.5,,82.88,85,,66.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.03,80.03,,62.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,87.75,90,,70.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.8,88,,68.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.25,87.75,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",3197530,CDM,420,RC,97530,HCPCS,Outpatient,,,97.5,58.5,,82.88,85,,66.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.35,32.15,,25.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.03,80.03,,62.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,87.75,90,,70.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.35,32.15,,25.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,31.35,32.15,,25.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.8,88,,68.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.28,33.11,,25.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.35,87.75,
"Blood test, comprehensive group of blood chemicals",1880019,CDM,300,RC,80053,HCPCS,Outpatient,,,97.58,58.55,,82.94,85,,66.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.09,80.03,,62.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,87.82,90,,70.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.29,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.87,88,,68.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.29,87.82,
"OXALATE, URINE  (MAYO)",1883945,CDM,300,RC,83945,HCPCS,Outpatient,,,97.75,58.65,,83.09,85,,66.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.23,80.03,,62.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,87.98,90,,70.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.02,88,,68.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,87.98,
"NICOTINE & METABOLITES, SERUM   (MAYO)",1883887,CDM,300,RC,80323,HCPCS,Outpatient,,,98.25,58.95,,83.51,85,,66.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.63,80.03,,62.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.43,90,,70.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,37.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.46,88,,69.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.75,88.43,
ALPHA-1 ACID GLYCOPROTEIN  (MAYO),1882986,CDM,300,RC,82985,HCPCS,Outpatient,,,98.5,59.1,,83.73,85,,66.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.83,80.03,,63.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,88.65,90,,70.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.68,88,,69.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,88.65,
CULTURE FUNGI BLOOD  (MAYO),1887103,CDM,300,RC,87103,HCPCS,Outpatient,,,98.75,59.25,,83.94,85,,67.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.03,80.03,,63.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,88.88,90,,71.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.9,88,,69.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.34,88.88,
"HANTAVIRUS, IGG  (MAYO)",1887492,CDM,300,RC,86790,HCPCS,Outpatient,,,98.75,59.25,,83.94,85,,67.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.03,80.03,,63.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,88.88,90,,71.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.9,88,,69.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,88.88,
"HANTAVIRUS, IGM  (MAYO)",1887494,CDM,300,RC,86790,HCPCS,Outpatient,,,98.75,59.25,,83.94,85,,67.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.03,80.03,,63.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,88.88,90,,71.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.9,88,,69.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,88.88,
CATH FOLEY 20FR 30CC RETENTION 3-WAY,49520,CDM,270,RC,,,Outpatient,,,99,59.4,,84.15,85,,67.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.83,32.15,,25.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.23,80.03,,63.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.1,90,,71.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.83,32.15,,25.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.83,32.15,,25.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.12,88,,69.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.78,33.11,,26.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.83,89.1,
EVEROLIMUS  (MAYO),1884872,CDM,300,RC,80169,HCPCS,Outpatient,,,99.04,59.42,,84.18,85,,67.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.26,80.03,,63.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.14,90,,71.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.16,88,,69.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.98,89.14,
NM SODIUM PERTECHNETATE,23001,CDM,254,RC,A9512,HCPCS,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
CARDIAC APNEA MONITOR,8005,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
NURSERY CARDIAC APNEA MTR,28020,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
CATH FOLEY 25FR 30CC HEMOSTATIC 2-WAY,49425,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
TRAY FOLEY 16FR SILICONE CAUTI,49573,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
BUR LONG 4 X 8MM DIAMOND COATED OVAL,49725,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
SENSOR EEG BIS EXTEND USE,49803,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
NEEDLE TOUEY 17 X 5,491735,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
NEEDLE TOUEY 17 X 6,491736,CDM,270,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
"HAEMOPHILUS INFLUENZAE B, IGG  (MAYO)",1882216,CDM,300,RC,86684,HCPCS,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.93,89.33,
"ALK. PHOS, BONE SPECIFIC  (MAYO)",1884081,CDM,300,RC,84080,HCPCS,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.07,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.07,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.59,89.33,
CRYPTOSPORIDIUM SMEAR  (MAYO),1887017,CDM,300,RC,87015,HCPCS,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.4,89.33,
CULTURE AFB BLOOD  (MAYO),1887115,CDM,300,RC,87116,HCPCS,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
FINE NEEDLE ASPIRATION,2188170,CDM,310,RC,88173,HCPCS,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,91.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,79.43,91.58,
ELECTRO SURGICAL LAPAR,93320,CDM,360,RC,,,Outpatient,,,99.25,59.55,,84.36,85,,67.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.43,80.03,,63.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.33,90,,71.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.91,32.15,,25.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.34,88,,69.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.86,33.11,,26.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.91,89.33,
AZMACORT (triamcinolone) 20GM INHALER,292108,CDM,636,RC,J7684,HCPCS,Outpatient,,,99.4,59.64,,84.49,85,,67.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.96,32.15,,25.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.55,80.03,,63.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.46,90,,71.57,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.96,32.15,,25.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.96,32.15,,25.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.47,88,,69.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.91,33.11,,26.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.96,89.46,
CEFTIN (CEFUROXIME) 125MG/5ML:100ML,29911,CDM,250,RC,,,Outpatient,,,99.5,59.7,,84.58,85,,67.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.63,80.03,,63.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.55,90,,71.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.56,88,,70.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.94,33.11,,26.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.99,89.55,
XOPENEX (levalbuterol) HFA 15G INHALER,291046,CDM,250,RC,,,Outpatient,,,99.5,59.7,,84.58,85,,67.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.63,80.03,,63.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.55,90,,71.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.56,88,,70.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.94,33.11,,26.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.99,89.55,
.CONCH COLUMN,30260,CDM,270,RC,,,Outpatient,,,99.5,59.7,,84.58,85,,67.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.63,80.03,,63.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.55,90,,71.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.99,32.15,,25.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.56,88,,70.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.94,33.11,,26.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.99,89.55,
BENZODIAZEPINE CONFIRMATION  (MAYO),1882644,CDM,300,RC,80346,HCPCS,Outpatient,,,99.5,59.7,,84.58,85,,67.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.63,80.03,,63.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.55,90,,71.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.56,88,,70.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.26,89.55,
"PROTEIN C RESISTANCE, APC-R  (MAYO)",1885735,CDM,300,RC,85307,HCPCS,Outpatient,,,99.5,59.7,,84.58,85,,67.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.63,80.03,,63.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.55,90,,71.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.56,88,,70.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.27,89.55,
ABSOLUTE CD4 & CD8 COUNT  (MAYO),1886352,CDM,310,RC,86360,HCPCS,Outpatient,,,99.5,59.7,,84.58,85,,67.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.63,80.03,,63.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,47.91,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.55,90,,71.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,47.91,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,59.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.56,88,,70.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,59.09,89.55,
CRYOGLOBULIN  (MAYO),1882595,CDM,300,RC,82595,HCPCS,Outpatient,,,99.75,59.85,,84.79,85,,67.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.83,80.03,,63.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.78,90,,71.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.78,88,,70.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.14,89.78,
"VISCOSITY, SERUM  (MAYO)",1885820,CDM,300,RC,85810,HCPCS,Outpatient,,,99.75,59.85,,84.79,85,,67.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,79.83,80.03,,63.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,89.78,90,,71.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.78,88,,70.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.69,89.78,
QUELICIN (SUCCINYLCHOLINE) 100MG/5ML SYR,300491,CDM,250,RC,,,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
NEEDLE SPINAL SPINOCAN 18GA X 3 1/2,491662,CDM,270,RC,,,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
"M PNEUMONIAE AB, IGM  (MAYO)",1886284,CDM,300,RC,86738,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.66,90,
Up to 3 views,22134,CDM,320,RC,73110,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",340,CDM,420,RC,97110,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
A technique used by physical therapists to restore normal body movement patterns,344,CDM,420,RC,97112,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311027,CDM,420,RC,97110,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",3401,CDM,430,RC,97110,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
A technique used by physical therapists to restore normal body movement patterns,3441,CDM,430,RC,97112,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
Therapy for speech or hearing,312005,CDM,440,RC,92507,HCPCS,Outpatient,,,100,60,,85,85,,68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.03,80.03,,64.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,90,90,,72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.15,32.15,,25.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,88,,70.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.11,33.11,,26.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.15,90,
SYNTOCINON SPRAY : 5ML,292039,CDM,250,RC,,,Outpatient,,,100.43,60.26,,85.37,85,,68.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.29,32.15,,25.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.37,80.03,,64.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.39,90,,72.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.29,32.15,,25.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.29,32.15,,25.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.38,88,,70.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.25,33.11,,26.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.29,90.39,
"FACTOR XIII, QL, REFLEX TO 1:1 MIX",1882064,CDM,300,RC,85291,HCPCS,Outpatient,,,100.5,60.3,,85.43,85,,68.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.43,80.03,,64.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90.45,90,,72.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.44,88,,70.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.18,90.45,
FACTOR XIII 1:1 MIX (MAYO),1882065,CDM,300,RC,85291,HCPCS,Outpatient,,,100.5,60.3,,85.43,85,,68.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.43,80.03,,64.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90.45,90,,72.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.44,88,,70.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.18,90.45,
HALOPERIDOL LEVEL  (MAYO),1882494,CDM,300,RC,80173,HCPCS,Outpatient,,,100.5,60.3,,85.43,85,,68.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.43,80.03,,64.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90.45,90,,72.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.44,88,,70.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.31,90.45,
Test to predict likelihood of gestational diabetes,1882951,CDM,300,RC,82951,HCPCS,Outpatient,,,100.5,60.3,,85.43,85,,68.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.43,80.03,,64.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90.45,90,,72.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.44,88,,70.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,90.45,
"COMPLEMENT, FUNCTIONAL EACH (MAYO)",1886163,CDM,300,RC,86161,HCPCS,Outpatient,,,100.5,60.3,,85.43,85,,68.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.43,80.03,,64.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90.45,90,,72.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.44,88,,70.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,90.45,
HIV-1 AB CONFIRM BY WESTERN BLOT  (MAYO),1886313,CDM,300,RC,86689,HCPCS,Outpatient,,,100.5,60.3,,85.43,85,,68.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.43,80.03,,64.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90.45,90,,72.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.44,88,,70.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.12,90.45,
IP VAC DAILY RENTAL,4381,CDM,420,RC,,,Outpatient,,,100.75,60.45,,85.64,85,,68.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.39,32.15,,25.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.63,80.03,,64.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.68,90,,72.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.39,32.15,,25.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.39,32.15,,25.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.66,88,,70.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.36,33.11,,26.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.39,90.68,
INTRALIPID 10%  500ML,296423,CDM,258,RC,,,Outpatient,,,100.94,60.56,,85.8,85,,68.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.45,32.15,,25.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.78,80.03,,64.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.85,90,,72.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.45,32.15,,25.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.45,32.15,,25.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.83,88,,71.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.42,33.11,,26.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.45,90.85,
TRAY WET SKIN SCRUB,492081,CDM,270,RC,,,Outpatient,,,100.94,60.56,,85.8,85,,68.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.45,32.15,,25.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.78,80.03,,64.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.85,90,,72.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.45,32.15,,25.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.45,32.15,,25.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.83,88,,71.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.42,33.11,,26.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.45,90.85,
FACTOR X ASSAY  (MAYO),1885213,CDM,300,RC,85260,HCPCS,Outpatient,,,101,60.6,,85.85,85,,68.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.83,80.03,,64.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,90.9,90,,72.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.88,88,,71.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.52,90.9,
OPTHETIC (PROPARACAINE) 0.5% OPTH 15ML,297752,CDM,250,RC,,,Outpatient,,,101.06,60.64,,85.9,85,,68.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.49,32.15,,25.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.88,80.03,,64.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.95,90,,72.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.49,32.15,,25.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.49,32.15,,25.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.93,88,,71.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.46,33.11,,26.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.49,90.95,
INBORN ERRORS OF METABOLISM   MAYO,1880098,CDM,300,RC,82128,HCPCS,Outpatient,,,101.25,60.75,,86.06,85,,68.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.03,80.03,,64.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.14,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,91.13,90,,72.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.14,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.1,88,,71.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.43,91.13,
CAFFEINE LEVEL  (MAYO),1883521,CDM,300,RC,80155,HCPCS,Outpatient,,,101.25,60.75,,86.06,85,,68.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.03,80.03,,64.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,39.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,91.13,90,,72.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.1,88,,71.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.44,91.13,
SUPRAX 100MG/5ML : 50ML,295188,CDM,250,RC,,,Outpatient,,,101.46,60.88,,86.24,85,,68.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.62,32.15,,26.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.2,80.03,,64.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.31,90,,73.05,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.62,32.15,,26.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.62,32.15,,26.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.28,88,,71.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.59,33.11,,26.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.62,91.31,
ARSENIC/CREATININE RATIO URINE  (MAYO),1883042,CDM,300,RC,82175,HCPCS,Outpatient,,,101.5,60.9,,86.28,85,,69.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.23,80.03,,64.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,91.35,90,,73.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.32,88,,71.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.86,91.35,
APTT MIX 1:1 (MAYO),1885312,CDM,300,RC,85732,HCPCS,Outpatient,,,101.5,60.9,,86.28,85,,69.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,81.23,80.03,,64.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,91.35,90,,73.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.32,88,,71.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.14,91.35,
NO SHOW AND LAST MINUTE CANCELATIONS,30004,CDM,270,RC,,,Outpatient,,,102,61.2,,86.7,85,,69.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.63,80.03,,65.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.8,90,,73.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.76,88,,71.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.77,33.11,,27.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.79,91.8,
"VERAPAMIL, CALAN LEVEL   (MAYO)",1880032,CDM,300,RC,,,Outpatient,,,102.25,61.35,,86.91,85,,69.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.87,32.15,,26.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.83,80.03,,65.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.03,90,,73.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.87,32.15,,26.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.87,32.15,,26.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.98,88,,71.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.85,33.11,,27.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.87,92.03,
ARIXTRA (fondaparinux) 2.5MG/0.5ML SC,293862,CDM,636,RC,J1652,HCPCS,Outpatient,,,102.35,61.41,,87,85,,69.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.91,32.15,,26.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.91,80.03,,65.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.12,90,,73.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.91,32.15,,26.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.91,32.15,,26.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.07,88,,72.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.89,33.11,,27.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.91,92.12,
TEQUIN 200MG/100ML PB *DISCONTINUED*,293517,CDM,250,RC,J1590,HCPCS,Outpatient,,,102.5,61.5,,87.13,85,,69.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.03,80.03,,65.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.25,90,,73.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.2,88,,72.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.94,33.11,,27.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.95,92.25,
CATH FOLEY 24FR 30CC RETENTION 3-WAY,49527,CDM,270,RC,,,Outpatient,,,102.5,61.5,,87.13,85,,69.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.03,80.03,,65.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.25,90,,73.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.2,88,,72.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.94,33.11,,27.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.95,92.25,
VOLATILE SCREEN BLOOD (MAYO),1882070,CDM,300,RC,80320,HCPCS,Outpatient,,,102.5,61.5,,87.13,85,,69.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.03,80.03,,65.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.25,90,,73.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.2,88,,72.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.59,92.25,
HSV MOLECULAR DETECTION PCR  (MAYO),1887538,CDM,300,RC,87529,HCPCS,Outpatient,,,102.5,61.5,,87.13,85,,69.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.03,80.03,,65.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,92.25,90,,73.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.2,88,,72.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,92.25,
Use of massage,349,CDM,420,RC,97124,HCPCS,Outpatient,,,102.5,61.5,,87.13,85,,69.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.03,80.03,,65.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.89,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,92.25,90,,73.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.89,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.2,88,,72.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.94,33.11,,27.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.95,92.25,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",3197110,CDM,420,RC,97110,HCPCS,Outpatient,,,102.5,61.5,,87.13,85,,69.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.03,80.03,,65.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,92.25,90,,73.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.2,88,,72.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.94,33.11,,27.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.95,92.25,
NICO CARDIAC OUTPUT,30382,CDM,730,RC,93799,HCPCS,Outpatient,,,102.5,61.5,,87.13,85,,69.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.03,80.03,,65.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,92.25,90,,73.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,32.95,32.15,,26.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.2,88,,72.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.94,33.11,,27.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.95,92.25,
THIOTEPA 15MG,293280,CDM,250,RC,,,Outpatient,,,102.75,61.65,,87.34,85,,69.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.23,80.03,,65.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.48,90,,73.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.42,88,,72.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.02,33.11,,27.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.03,92.48,
ELECTRICAL STIMULATION - SUPERVISED,325,CDM,420,RC,G0283,HCPCS,Outpatient,,,102.75,61.65,,87.34,85,,69.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.23,80.03,,65.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.74,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,92.48,90,,73.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.74,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.42,88,,72.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.02,33.11,,27.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.03,92.48,
One time use unattended,3190283,CDM,420,RC,97014,HCPCS,Outpatient,,,102.75,61.65,,87.34,85,,69.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.23,80.03,,65.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.48,90,,73.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.03,32.15,,26.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.42,88,,72.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.02,33.11,,27.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.03,92.48,
PATANOL (olopatadine)0.1% OPTH SOLN,297922,CDM,250,RC,,,Outpatient,,,103,61.8,,87.55,85,,70.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.11,32.15,,26.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.43,80.03,,65.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.7,90,,74.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.11,32.15,,26.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.11,32.15,,26.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.64,88,,72.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.1,33.11,,27.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.11,92.7,
DRUG SCREEN CLASS LIST A,1884446,CDM,300,RC,80301,HCPCS,Outpatient,,,103,61.8,,87.55,85,,70.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.11,32.15,,26.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.43,80.03,,65.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.7,90,,74.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.11,32.15,,26.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.11,32.15,,26.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.64,88,,72.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.1,33.11,,27.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.11,92.7,
PRIMIDONE SERUM  (MAYO),1882206,CDM,300,RC,80188,HCPCS,Outpatient,,,103.25,61.95,,87.76,85,,70.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.63,80.03,,66.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.92,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,92.93,90,,74.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.92,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.86,88,,72.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.86,92.93,
Testing for presence of drug,1883839,CDM,300,RC,80307,HCPCS,Outpatient,,,103.5,62.1,,87.98,85,,70.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.83,80.03,,66.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,93.15,90,,74.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.08,88,,72.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.16,93.15,
..TOBRAMYCIN,1884810,CDM,300,RC,80200,HCPCS,Outpatient,,,103.5,62.1,,87.98,85,,70.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,82.83,80.03,,66.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,93.15,90,,74.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.84,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.08,88,,72.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.84,93.15,
P/T NPWT >50cm2,3981,CDM,420,RC,97606,HCPCS,Outpatient,,,103.5,62.1,,87.98,85,,70.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.83,80.03,,66.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,93.15,90,,74.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.08,88,,72.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.27,33.11,,27.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.28,93.15,
P/T 2-3 LAYER COMPRESSION WRAPS,39052,CDM,420,RC,29581,HCPCS,Outpatient,,,103.5,62.1,,87.98,85,,70.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.83,80.03,,66.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,93.15,90,,74.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.08,88,,72.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.27,33.11,,27.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.28,93.15,
PRECEDEX(dexmedetomidine) 200MCG/50ML PB,301850,CDM,250,RC,,,Outpatient,,,103.8,62.28,,88.23,85,,70.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.37,32.15,,26.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.07,80.03,,66.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.42,90,,74.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.37,32.15,,26.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.37,32.15,,26.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.34,88,,73.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.37,33.11,,27.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.37,93.42,
Acute hepatitis panel,1880060,CDM,300,RC,80074,HCPCS,Outpatient,,,104,62.4,,88.4,85,,70.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,83.23,80.03,,66.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.58,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,93.6,90,,74.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.58,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,59.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.52,88,,73.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,59.89,93.6,
MEPROBAMATE  (MAYO),1883805,CDM,300,RC,,,Outpatient,,,104.25,62.55,,88.61,85,,70.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.52,32.15,,26.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.43,80.03,,66.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.83,90,,75.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.52,32.15,,26.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.52,32.15,,26.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.74,88,,73.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.52,33.11,,27.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.52,93.83,
Pathology test,2188340,CDM,310,RC,88342,HCPCS,Outpatient,,,104.5,62.7,,88.83,85,,71.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,83.63,80.03,,66.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,94.05,90,,75.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.96,88,,73.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,71.58,94.05,
A type of physical therapy,3197116,CDM,420,RC,97116,HCPCS,Outpatient,,,104.5,62.7,,88.83,85,,71.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.6,32.15,,26.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.63,80.03,,66.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,94.05,90,,75.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.6,32.15,,26.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,33.6,32.15,,26.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.96,88,,73.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.6,33.11,,27.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.6,94.05,
"FRANCISELLA TULARENSIS AB, SERUM  (MAYO)",1886011,CDM,300,RC,86000,HCPCS,Outpatient,,,104.75,62.85,,89.04,85,,71.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,83.83,80.03,,67.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.11,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,94.28,90,,75.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.11,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.18,88,,73.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.78,94.28,
CATH FOLEY 10FR 3ML PEDI 2-WAY,49422,CDM,270,RC,,,Outpatient,,,105,63,,89.25,85,,71.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.76,32.15,,27.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.03,80.03,,67.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,75.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.76,32.15,,27.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.76,32.15,,27.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.4,88,,73.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.77,33.11,,27.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.76,94.5,
NEEDLE FLEX TEGRESS,4999003,CDM,270,RC,,,Outpatient,,,105,63,,89.25,85,,71.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.76,32.15,,27.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.03,80.03,,67.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,75.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.76,32.15,,27.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.76,32.15,,27.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.4,88,,73.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.77,33.11,,27.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.76,94.5,
"ALDOSTERONE, URINE  (MAYO)",1882089,CDM,300,RC,82088,HCPCS,Outpatient,,,105,63,,89.25,85,,71.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.03,80.03,,67.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,94.5,90,,75.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.4,88,,73.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.25,94.5,
"ARSENIC, URINE  (MAYO)",1882175,CDM,300,RC,82175,HCPCS,Outpatient,,,105,63,,89.25,85,,71.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.03,80.03,,67.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,94.5,90,,75.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.4,88,,73.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.86,94.5,
"FRUCTOSE, SEMEN  (MAYO)",1882757,CDM,300,RC,82757,HCPCS,Outpatient,,,105,63,,89.25,85,,71.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.03,80.03,,67.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.68,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,94.5,90,,75.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.68,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.4,88,,73.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.82,94.5,
VANTIN (cefpodoxime) 50MG/5ML : 100ML,292321,CDM,250,RC,,,Outpatient,,,105.32,63.19,,89.52,85,,71.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.86,32.15,,27.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.29,80.03,,67.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.79,90,,75.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.86,32.15,,27.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.86,32.15,,27.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.68,88,,74.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.87,33.11,,27.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.86,94.79,
OXISENSOR II ADULT DIGIT LONG,49801,CDM,270,RC,,,Outpatient,,,105.5,63.3,,89.68,85,,71.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.92,32.15,,27.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.43,80.03,,67.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.95,90,,75.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.92,32.15,,27.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.92,32.15,,27.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.84,88,,74.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.93,33.11,,27.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.92,94.95,
FIBROSURE HAPTOGLOBIN QUANT (MAYO),1883881,CDM,300,RC,83010,HCPCS,Outpatient,,,105.5,63.3,,89.68,85,,71.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.43,80.03,,67.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,94.95,90,,75.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.84,88,,74.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.69,94.95,
"ALDACTONE LEVEL (NMS),  (MAYO)",1884996,CDM,300,RC,80299,HCPCS,Outpatient,,,105.5,63.3,,89.68,85,,71.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.43,80.03,,67.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,94.95,90,,75.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.84,88,,74.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,94.95,
OB OBSERVATION TRIAGE PER HR.,6006,CDM,450,RC,99281,HCPCS,Outpatient,,,105.5,63.3,,89.68,85,,71.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.43,80.03,,67.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.98,102,,,fee schedule,Pays at 102% of CMS APC rate,94.95,90,,75.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.98,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.84,88,,74.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.43,385,
PSA (prostate specific antigen),1884160,CDM,300,RC,84153,HCPCS,Outpatient,,,105.75,63.45,,89.89,85,,71.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.63,80.03,,67.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,95.18,90,,76.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.06,88,,74.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.13,95.18,
SYNTHROID (levothyroxine) 200 MCG INJ,293294,CDM,250,RC,,,Outpatient,,,105.84,63.5,,89.96,85,,71.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.03,32.15,,27.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.7,80.03,,67.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.26,90,,76.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.03,32.15,,27.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.03,32.15,,27.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.14,88,,74.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.04,33.11,,28.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.03,95.26,
"COBALT, SERUM  (MAYO)",1882528,CDM,300,RC,83018,HCPCS,Outpatient,,,106,63.6,,90.1,85,,72.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,84.83,80.03,,67.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,95.4,90,,76.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.28,88,,74.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.61,95.4,
COMPRESSION SUPPORT BURN GARMENT FT TO K,31143,CDM,270,RC,A6507,HCPCS,Outpatient,,,106.5,63.9,,90.53,85,,72.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.23,80.03,,68.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.85,90,,76.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.72,88,,74.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.26,33.11,,28.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.24,95.85,
ANEST SUP EA ADD 1/2 HR-OR,13010,CDM,370,RC,,,Outpatient,,,106.5,63.9,,90.53,85,,72.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.23,80.03,,68.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.85,90,,76.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.72,88,,74.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.26,33.11,,28.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.24,95.85,
TUBE CONNECTING 1/4x12 FT NONCONDUCTIVE,493886,CDM,270,RC,,,Outpatient,,,106.6,63.96,,90.61,85,,72.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.27,32.15,,27.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.31,80.03,,68.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.94,90,,76.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.27,32.15,,27.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.27,32.15,,27.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.81,88,,75.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.3,33.11,,28.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.27,95.94,
ADVNCED CARE PLAN  ADDL 30 MIN,8799498,CDM,940,RC,99498,HCPCS,Outpatient,,,106.61,63.97,,90.62,85,,72.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.28,32.15,,27.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.32,80.03,,68.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.95,90,,76.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.28,32.15,,27.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.28,32.15,,27.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.82,88,,75.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.3,33.11,,28.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.28,95.95,
MCCONNELL TAPING KITS,31142,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
CATHETER TROCAR 16FR X 10  STERILE,49240,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
CATHETER TROCAR 20FR X 10  STERILE,49241,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
CATHETER TROCAR 24FR X 10  STERILE,49242,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
CATHETER TROCAR 28FR X 10  STERILE,49243,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
CATH THORACIC 28FR RIGHT ANGLE 20,49597,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
CATH THORACIC 32FR RIGHT ANGLE 20,49598,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
NEEDLE KOPANS 21GA 3CM DKBL-21-3.0,225049,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
NEEDLE KOPAN 21GA 5CM BREAST LOCALIZATIO,225050,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
NEEDLE KOPANS 21GA 7.5CM DKBL-21-7.5,225051,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
LUMBAR SUPPORT VELCRO CLOSURE XS - XL,314018,CDM,270,RC,L0515,HCPCS,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
BRACE CLAVICAL SMALL,491178,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
DRESSING DUODERM CGF X-THIN 6 X 6,493268,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
SYSTEM BANDAGING PROFORE,493269,CDM,270,RC,A6208,HCPCS,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
FILTER RAPID VOLUME INFUSER,496503,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
STOCKINETTE IMPERVIOUS 9X36 STERILE MED,499811,CDM,270,RC,,,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
STERILE WHIRLPOOL: SMALL TANK,329,CDM,420,RC,97022,HCPCS,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",333,CDM,420,RC,97035,HCPCS,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",3197035,CDM,420,RC,97035,HCPCS,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.99,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
One time use unattended,3251,CDM,430,RC,97014,HCPCS,Outpatient,,,106.75,64.05,,90.74,85,,72.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.43,80.03,,68.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.08,90,,76.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.32,32.15,,27.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.94,88,,75.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.34,33.11,,28.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.32,96.08,
VIBRAMYCIN(doxycycline)100MG /NS 100MLPB,293207,CDM,250,RC,,,Outpatient,,,107,64.2,,90.95,85,,72.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.4,32.15,,27.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.63,80.03,,68.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.3,90,,77.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.4,32.15,,27.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.4,32.15,,27.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.16,88,,75.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.43,33.11,,28.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.4,96.3,
AIRWAY 26FR NASOPHARYNGEAL,490025,CDM,270,RC,,,Outpatient,,,107,64.2,,90.95,85,,72.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.4,32.15,,27.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.63,80.03,,68.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.3,90,,77.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.4,32.15,,27.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.4,32.15,,27.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.16,88,,75.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.43,33.11,,28.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.4,96.3,
VANCOCIN (vancomycin) 250MG CAP,29767,CDM,250,RC,,,Outpatient,,,107.3,64.38,,91.21,85,,72.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.5,32.15,,27.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.87,80.03,,68.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.57,90,,77.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.5,32.15,,27.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.5,32.15,,27.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.42,88,,75.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.53,33.11,,28.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.5,96.57,
"ALPHA FETOPROTEIN, PERITONEAL FL  (MAYO)",1884884,CDM,300,RC,86316,HCPCS,Outpatient,,,107.34,64.4,,91.24,85,,72.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.9,80.03,,68.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,96.61,90,,77.29,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.46,88,,75.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.16,96.61,
SPLINT COLLES SMALL LEFT,490105,CDM,270,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
SPLINT COLLES SMALL RIGHT,490107,CDM,270,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
SPLINT COLLES MEDIUM RIGHT,490108,CDM,270,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
SPLINT COLLES LARGE RIGHT,490109,CDM,270,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
SPLINT COLLES MEDIUM LEFT,490111,CDM,270,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
SPLINT COLLES LARGE LEFT,490113,CDM,270,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
DRAPE EXTREMITY 89  X 128,499276,CDM,270,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
INJECTION IM MUSCLE,22344,CDM,320,RC,77076,HCPCS,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
TRAY SIGMOID,14250,CDM,450,RC,,,Outpatient,,,107.5,64.5,,91.38,85,,73.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.03,80.03,,68.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.75,90,,77.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.56,32.15,,27.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.6,88,,75.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.59,33.11,,28.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.56,96.75,
DOBUTREX (DOBUTamine) 500mg/250mL Drip,296106,CDM,258,RC,J1250,HCPCS,Outpatient,,,107.52,64.51,,91.39,85,,73.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.05,80.03,,68.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.77,90,,77.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.62,88,,75.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.82,96.77,
"PTH, INTACT  (MAYO)",1883972,CDM,300,RC,83970,HCPCS,Outpatient,,,107.83,64.7,,91.66,85,,73.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.3,80.03,,69.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,42.1,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,97.05,90,,77.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.1,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.89,88,,75.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.9,97.05,
BAG COLLECTION BILE REGULAR,49160,CDM,270,RC,,,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
CATH FOLEY 8FR 3ML PEDI 2-WAY SILICONE,49421,CDM,270,RC,,,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
SHOE POST-OP FEMALE SMALL,491023,CDM,270,RC,,,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
SHOE POST-OP FEMALE MEDIUM,491024,CDM,270,RC,,,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
SHOE POST-OP MALE SMALL,491026,CDM,270,RC,,,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
SHOE POST-OP MALE MEDIUM,491027,CDM,270,RC,,,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
WOUND ADHESIVE,14030,CDM,450,RC,G0168,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
ENT PROCEDURE/SERVICE,1492599,CDM,450,RC,,,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
ISOVUE 150,293404,CDM,255,RC,,,Outpatient,,,108.15,64.89,,91.93,85,,73.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.77,32.15,,27.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.55,80.03,,69.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.34,90,,77.87,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.77,32.15,,27.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.77,32.15,,27.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.17,88,,76.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.81,33.11,,28.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.77,97.34,
ISOVUE 100ML,265024,CDM,250,RC,,,Outpatient,,,108.25,64.95,,92.01,85,,73.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.8,32.15,,27.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.63,80.03,,69.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.43,90,,77.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.8,32.15,,27.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.8,32.15,,27.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.26,88,,76.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.84,33.11,,28.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.8,97.43,
"ID MALDI-TOF MS, AFB  (MAYO)",1887101,CDM,300,RC,87118,HCPCS,Outpatient,,,108.5,65.1,,92.23,85,,73.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.88,32.15,,27.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.83,80.03,,69.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,97.65,90,,78.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.88,32.15,,27.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,34.88,32.15,,27.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.48,88,,76.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.92,33.11,,28.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.88,97.65,
STETHOSCOPE ESOPHAGEAL 18FR,493110,CDM,270,RC,,,Outpatient,,,108.75,65.25,,92.44,85,,73.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.96,32.15,,27.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.03,80.03,,69.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.88,90,,78.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.96,32.15,,27.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.96,32.15,,27.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.7,88,,76.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.01,33.11,,28.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.96,97.88,
"ANTI-DIURETIC HORMONE, ADH  (MAYO)",1884588,CDM,300,RC,84588,HCPCS,Outpatient,,,108.75,65.25,,92.44,85,,73.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.03,80.03,,69.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,34.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,97.88,90,,78.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.7,88,,76.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,42.69,97.88,
"HEAVY METAL SCREEN, URINE 24 HR  (MAYO)",1886297,CDM,300,RC,83015,HCPCS,Outpatient,,,108.75,65.25,,92.44,85,,73.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.03,80.03,,69.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,97.88,90,,78.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.7,88,,76.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.68,97.88,
"HEAVY METAL SCREEN, BLOOD  (MAYO)",1886298,CDM,300,RC,83015,HCPCS,Outpatient,,,108.75,65.25,,92.44,85,,73.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.03,80.03,,69.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,97.88,90,,78.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.7,88,,76.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.68,97.88,
HIV-2  (MAYO),1886702,CDM,300,RC,86702,HCPCS,Outpatient,,,108.75,65.25,,92.44,85,,73.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.03,80.03,,69.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,97.88,90,,78.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.7,88,,76.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.19,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.75,97.88,
SUPPORTER MED ATHLETIC ADULT 33-38,493355,CDM,270,RC,,,Outpatient,,,109.25,65.55,,92.86,85,,74.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.12,32.15,,28.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.43,80.03,,69.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.33,90,,78.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.12,32.15,,28.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.12,32.15,,28.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.14,88,,76.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.17,33.11,,28.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.12,98.33,
Urine test to measure albumin,1884894,CDM,300,RC,82043,HCPCS,Outpatient,,,109.35,65.61,,92.95,85,,74.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.51,80.03,,70.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,98.42,90,,78.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.23,88,,76.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.28,98.42,
SUPPORTER LG ATHLETIC ADULT 38-44,493354,CDM,270,RC,,,Outpatient,,,109.5,65.7,,93.08,85,,74.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.2,32.15,,28.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.63,80.03,,70.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.55,90,,78.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.2,32.15,,28.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.5,,,,Other,Not Separately reimbursable,35.2,32.15,,28.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.36,88,,77.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.26,33.11,,29.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.2,98.55,
ACTIVATED PROTEIN-C RESISTANCE  (MAYO),1885305,CDM,300,RC,85307,HCPCS,Outpatient,,,109.5,65.7,,93.08,85,,74.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.63,80.03,,70.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,98.55,90,,78.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.27,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.36,88,,77.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.27,98.55,
Blood test for an STD,1887491,CDM,300,RC,87591,HCPCS,Outpatient,,,109.65,65.79,,93.2,85,,74.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.75,80.03,,70.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,98.69,90,,78.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.49,88,,77.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.42,98.69,
ISOLETTES,8065,CDM,270,RC,,,Outpatient,,,109.75,65.85,,93.29,85,,74.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.83,80.03,,70.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.78,90,,79.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.75,,,,Other,Not Separately reimbursable,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.58,88,,77.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.34,33.11,,29.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.28,98.78,
RADIANT WARMER,8066,CDM,270,RC,,,Outpatient,,,109.75,65.85,,93.29,85,,74.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.83,80.03,,70.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.78,90,,79.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.75,,,,Other,Not Separately reimbursable,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.58,88,,77.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.34,33.11,,29.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.28,98.78,
SENSOR OXI II D-20 PEDI,496390,CDM,270,RC,,,Outpatient,,,109.75,65.85,,93.29,85,,74.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.83,80.03,,70.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.78,90,,79.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.75,,,,Other,Not Separately reimbursable,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.58,88,,77.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.34,33.11,,29.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.28,98.78,
SET TRANSFER 48,4980081,CDM,270,RC,,,Outpatient,,,109.75,65.85,,93.29,85,,74.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.83,80.03,,70.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.78,90,,79.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.75,,,,Other,Not Separately reimbursable,35.28,32.15,,28.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.58,88,,77.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.34,33.11,,29.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.28,98.78,
Blood test to assist with diagnosis,2188316,CDM,310,RC,88312,HCPCS,Outpatient,,,109.75,65.85,,93.29,85,,74.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,87.83,80.03,,70.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,98.78,90,,79.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,43.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.58,88,,77.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,43.39,98.78,
EPHEDRINE : 50MG INJ,293076,CDM,250,RC,,,Outpatient,,,109.8,65.88,,93.33,85,,74.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.3,32.15,,28.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,87.87,80.03,,70.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.82,90,,79.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.3,32.15,,28.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.8,,,,Other,Not Separately reimbursable,35.3,32.15,,28.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.62,88,,77.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.35,33.11,,29.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.3,98.82,
"ANTIDEPRESSANTS, SERTRALINE  (MAYO)",1882046,CDM,300,RC,80332,HCPCS,Outpatient,,,110,66,,93.5,85,,74.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.03,80.03,,70.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99,90,,79.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.8,88,,77.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.42,33.11,,29.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.37,99,
P/T ORTHOTIC SHOE FOR DIABETIC ONLY,31128,CDM,420,RC,A5503,HCPCS,Outpatient,,,110,66,,93.5,85,,74.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.03,80.03,,70.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99,90,,79.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.8,88,,77.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.42,33.11,,29.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.37,99,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311107,CDM,420,RC,97110,HCPCS,Outpatient,,,110,66,,93.5,85,,74.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.03,80.03,,70.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,99,90,,79.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,35.37,32.15,,28.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.8,88,,77.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.42,33.11,,29.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.37,99,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1886681,CDM,300,RC,83516,HCPCS,Outpatient,,,110.12,66.07,,93.6,85,,74.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.13,80.03,,70.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,99.11,90,,79.29,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.91,88,,77.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,99.11,
MISC DRUG 100,29905,CDM,250,RC,,,Outpatient,,,110.21,66.13,,93.68,85,,74.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.43,32.15,,28.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.2,80.03,,70.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.19,90,,79.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.43,32.15,,28.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.43,32.15,,28.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.98,88,,77.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.49,33.11,,29.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.43,99.19,
SILVADENE (SILVER SULFADIAZINE) 1000GM,297079,CDM,250,RC,,,Outpatient,,,110.21,66.13,,93.68,85,,74.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.43,32.15,,28.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.2,80.03,,70.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.19,90,,79.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.43,32.15,,28.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.43,32.15,,28.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.98,88,,77.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.49,33.11,,29.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.43,99.19,
P/T MIN EXUDATE WOUND,3926,CDM,420,RC,97799,HCPCS,Outpatient,,,110.3,66.18,,93.76,85,,75.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.46,32.15,,28.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.27,80.03,,70.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.27,90,,79.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.46,32.15,,28.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.46,32.15,,28.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.06,88,,77.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.52,33.11,,29.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.46,99.27,
P/T MOD EXUDATE WOUNDS,3927,CDM,420,RC,97799,HCPCS,Outpatient,,,110.3,66.18,,93.76,85,,75.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.46,32.15,,28.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.27,80.03,,70.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.27,90,,79.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.46,32.15,,28.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.46,32.15,,28.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.06,88,,77.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.52,33.11,,29.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.46,99.27,
SYNTHETIC MARIJUANA SCREEN  (MAYO),1880109,CDM,300,RC,80301,HCPCS,Outpatient,,,110.5,66.3,,93.93,85,,75.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.53,32.15,,28.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.43,80.03,,70.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.45,90,,79.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.53,32.15,,28.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.53,32.15,,28.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.24,88,,77.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.59,33.11,,29.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.53,99.45,
"PAXIL, PAROXETINE  (MAYO)",1882488,CDM,300,RC,80299,HCPCS,Outpatient,,,110.5,66.3,,93.93,85,,75.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.43,80.03,,70.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,99.45,90,,79.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.24,88,,77.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,99.45,
"TOXOPLASMOSIS, IGG  (MAYO)",1886778,CDM,300,RC,86777,HCPCS,Outpatient,,,110.5,66.3,,93.93,85,,75.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.43,80.03,,70.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,99.45,90,,79.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.24,88,,77.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,99.45,
"TOXOPLASMOSIS, IGM   (MAYO)",1886779,CDM,300,RC,86778,HCPCS,Outpatient,,,110.5,66.3,,93.93,85,,75.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.43,80.03,,70.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,99.45,90,,79.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.24,88,,77.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.11,99.45,
BLADE SAGITTAL MICRO FINE 5.5 X 18.5,499814,CDM,270,RC,,,Outpatient,,,110.75,66.45,,94.14,85,,75.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.61,32.15,,28.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.63,80.03,,70.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.68,90,,79.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.61,32.15,,28.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.61,32.15,,28.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.46,88,,77.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.67,33.11,,29.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.61,99.68,
HIV-1 AB (MAYO),1886306,CDM,300,RC,86701,HCPCS,Outpatient,,,110.75,66.45,,94.14,85,,75.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.63,80.03,,70.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,99.68,90,,79.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.46,88,,77.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.7,99.68,
PRIMAXIN (imipenem): 500 MG IM VIAL,293132,CDM,636,RC,J0743,HCPCS,Outpatient,,,110.99,66.59,,94.34,85,,75.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.83,80.03,,71.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.89,90,,79.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,7.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.67,88,,78.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.17,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.93,99.89,
CARBATROL (CARBAM FREE/TOTAL)    MAYO,1880297,CDM,300,RC,80157,HCPCS,Outpatient,,,111,66.6,,94.35,85,,75.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.83,80.03,,71.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,99.9,90,,79.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.68,88,,78.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.5,99.9,
"FREE CORTISOL, SERUM  (MAYO)",1882530,CDM,300,RC,82530,HCPCS,Outpatient,,,111,66.6,,94.35,85,,75.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.83,80.03,,71.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,99.9,90,,79.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.68,88,,78.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.02,99.9,
"BENZODIAZEPINES, 13 OR MORE  (MAYO)",1890001,CDM,300,RC,80347,HCPCS,Outpatient,,,111,66.6,,94.35,85,,75.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,88.83,80.03,,71.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.9,90,,79.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,23.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.68,88,,78.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.26,99.9,
"Radiologic examination of the neck/spine, 4-5 views",22324,CDM,320,RC,72050,HCPCS,Outpatient,,,111,66.6,,94.35,85,,75.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.69,32.15,,28.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.83,80.03,,71.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,99.9,90,,79.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.69,32.15,,28.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,35.69,32.15,,28.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.68,88,,78.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.75,33.11,,29.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.69,99.9,
SHOE POST-OP FEMALE LARGE,491025,CDM,270,RC,,,Outpatient,,,111.25,66.75,,94.56,85,,75.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.03,80.03,,71.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.13,90,,80.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.9,88,,78.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.83,33.11,,29.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.77,100.13,
SHOE POST-OP MALE LARGE,491028,CDM,270,RC,,,Outpatient,,,111.25,66.75,,94.56,85,,75.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.03,80.03,,71.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.13,90,,80.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.9,88,,78.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.83,33.11,,29.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.77,100.13,
SHOE POST-OP MALE X-LARGE,491033,CDM,270,RC,,,Outpatient,,,111.25,66.75,,94.56,85,,75.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.03,80.03,,71.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.13,90,,80.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.77,32.15,,28.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.9,88,,78.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.83,33.11,,29.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.77,100.13,
DECUBITUS LEG SUPPORT,314035,CDM,270,RC,,,Outpatient,,,111.5,66.9,,94.78,85,,75.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.23,80.03,,71.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.35,90,,80.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.12,88,,78.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.92,33.11,,29.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.85,100.35,
Coagulation assessment blood test,1887531,CDM,300,RC,85730,HCPCS,Outpatient,,,111.5,66.9,,94.78,85,,75.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.23,80.03,,71.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.35,90,,80.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.12,88,,78.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.54,100.35,
"P/T REASSESSMENT, BASIC",311,CDM,424,RC,97164,HCPCS,Outpatient,,,111.5,66.9,,94.78,85,,75.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.23,80.03,,71.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,67.47,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,100.35,90,,80.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.47,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.12,88,,78.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.92,33.11,,29.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.85,100.35,
A technique used by physical therapists to restore normal body movement patterns,593027,CDM,430,RC,97112,HCPCS,Outpatient,,,111.5,66.9,,94.78,85,,75.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.23,80.03,,71.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,100.35,90,,80.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.12,88,,78.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.92,33.11,,29.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.85,100.35,
"O/T REASSESSMENT, BASIC",3111,CDM,434,RC,97168,HCPCS,Outpatient,,,111.5,66.9,,94.78,85,,75.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.23,80.03,,71.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,67.17,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,100.35,90,,80.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.17,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,35.85,32.15,,28.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.12,88,,78.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.92,33.11,,29.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.85,100.35,
OPIATES 1 OR MORE  (MAYO),1882790,CDM,300,RC,80361,HCPCS,Outpatient,,,111.52,66.91,,94.79,85,,75.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.25,80.03,,71.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.37,90,,80.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.14,88,,78.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.97,100.37,
"BORDETELLA PERTUSSIS, PCR  (MAYO)",1887004,CDM,300,RC,87798,HCPCS,Outpatient,,,111.75,67.05,,94.99,85,,75.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.43,80.03,,71.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.58,90,,80.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.34,88,,78.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,100.58,
"BORDETELLA PARAPERTUSSIS, PCR  (MAYO)",1887005,CDM,300,RC,87798,HCPCS,Outpatient,,,111.75,67.05,,94.99,85,,75.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.43,80.03,,71.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.58,90,,80.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.34,88,,78.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,100.58,
"HSV, CSF & OTHER BODY FLUID, PCR  (MAYO)",1887527,CDM,300,RC,87529,HCPCS,Outpatient,,,111.75,67.05,,94.99,85,,75.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.43,80.03,,71.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.58,90,,80.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.34,88,,78.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,100.58,
FOLATE(MAYO),1884915,CDM,300,RC,82746,HCPCS,Outpatient,,,111.8,67.08,,95.03,85,,76.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.47,80.03,,71.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.62,90,,80.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.38,88,,78.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.49,100.62,
ABG COLLECTION,30330,CDM,761,RC,36600,HCPCS,Outpatient,,,111.95,67.17,,95.16,85,,76.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.99,32.15,,28.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.59,80.03,,71.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,100.76,90,,80.61,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.99,32.15,,28.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,35.99,32.15,,28.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.52,88,,78.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.07,33.11,,29.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.99,100.76,
LAB DRAW CATHETER / PICC LINE,36592,CDM,761,RC,36592,HCPCS,Outpatient,,,111.95,67.17,,95.16,85,,76.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.99,32.15,,28.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.59,80.03,,71.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,100.76,90,,80.61,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.99,32.15,,28.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,35.99,32.15,,28.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.52,88,,78.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.07,33.11,,29.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.99,100.76,
Blood test used to diagnose heart failure,1883526,CDM,300,RC,83880,HCPCS,Outpatient,,,112,67.2,,95.2,85,,76.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.63,80.03,,71.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.8,90,,80.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.56,88,,78.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,42.69,100.8,
PSA (prostate specific antigen),1884151,CDM,300,RC,84153,HCPCS,Outpatient,,,112,67.2,,95.2,85,,76.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.63,80.03,,71.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.8,90,,80.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.56,88,,78.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.13,100.8,
RETICULIN IGA TITER  (MAYO),1886267,CDM,300,RC,86256,HCPCS,Outpatient,,,112,67.2,,95.2,85,,76.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.63,80.03,,71.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.8,90,,80.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.56,88,,78.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,100.8,
ANAEROBIC ANTIMICROBIAL SENSITIVITY,1887182,CDM,300,RC,87181,HCPCS,Outpatient,,,112,67.2,,95.2,85,,76.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.63,80.03,,71.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,100.8,90,,80.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.56,88,,78.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,100.8,
EMERGENCY COURIER SERVICE,2096392,CDM,391,RC,,,Outpatient,,,112,67.2,,95.2,85,,76.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.63,80.03,,71.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.8,90,,80.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.56,88,,78.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.08,33.11,,29.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.01,100.8,
AZACTAM  (aztreonam) 2GM / NS 100ML PB,293016,CDM,250,RC,S0073,HCPCS,Outpatient,,,112.02,67.21,,95.22,85,,76.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.65,80.03,,71.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.82,90,,80.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.58,88,,78.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.09,33.11,,29.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.01,100.82,
AZA SITE (azithromycin) OPTH SOLN 2.5ML,297526,CDM,250,RC,,,Outpatient,,,112.25,67.35,,95.41,85,,76.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.09,32.15,,28.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.83,80.03,,71.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.03,90,,80.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.09,32.15,,28.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.09,32.15,,28.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.78,88,,79.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.17,33.11,,29.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.09,101.03,
AIRWAY 30FR NASOPHARYNGEAL,490027,CDM,270,RC,,,Outpatient,,,112.25,67.35,,95.41,85,,76.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.09,32.15,,28.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.83,80.03,,71.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.03,90,,80.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.09,32.15,,28.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.09,32.15,,28.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.78,88,,79.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.17,33.11,,29.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.09,101.03,
ALKALINE PHOSHATASE ISOENZYMES  (MAYO),1884082,CDM,300,RC,84080,HCPCS,Outpatient,,,112.5,67.5,,95.63,85,,76.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.03,80.03,,72.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.07,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,101.25,90,,81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.07,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99,88,,79.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.59,101.25,
LEUKO ADHESION DEFICIENCY PANEL  (MAYO),1888183,CDM,300,RC,88184,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,46.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,46.1,101.48,
DEBRIDEMENT OF NAIL NAY METHOD 1-5,1411720,CDM,450,RC,11720,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
Removal of 6 or more nails,1411721,CDM,450,RC,11721,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
EVAC. SUBUNGUAL HEM,1411740,CDM,450,RC,11740,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
"STRAPPING; SHOULDER (EG, VELPEAU)",1429240,CDM,450,RC,29240,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
STRAPPING; KNEE,1429530,CDM,450,RC,29530,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
STRAPPING; TOES,1429550,CDM,450,RC,29550,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
1 Y/O CUTDOWN VENIPUNCTURE,1436420,CDM,450,RC,36420,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
RHYTHM ECG 1-3 LEADS TRACING ONLY W/O IN,1493041,CDM,450,RC,93041,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
PHLEBOTOMY,1499195,CDM,450,RC,99195,HCPCS,Outpatient,,,112.75,67.65,,95.84,85,,76.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.23,80.03,,72.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,101.48,90,,81.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,36.25,32.15,,29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.22,88,,79.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.33,33.11,,29.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.25,101.48,
SLING ARM CHILD,491226,CDM,270,RC,,,Outpatient,,,113,67.8,,96.05,85,,76.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.33,32.15,,29.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.43,80.03,,72.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.7,90,,81.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.33,32.15,,29.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.33,32.15,,29.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.44,88,,79.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.41,33.11,,29.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.33,101.7,
.VENTILATOR CIRCUIT,30175,CDM,270,RC,,,Outpatient,,,113.13,67.88,,96.16,85,,76.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.37,32.15,,29.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.54,80.03,,72.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.82,90,,81.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.37,32.15,,29.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.37,32.15,,29.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.55,88,,79.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.46,33.11,,29.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.37,101.82,
CT BONE BX TRAY,26090,CDM,270,RC,,,Outpatient,,,113.25,67.95,,96.26,85,,77.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.41,32.15,,29.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.63,80.03,,72.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.93,90,,81.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.41,32.15,,29.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.41,32.15,,29.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.66,88,,79.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.5,33.11,,30,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.41,101.93,
17 KETOGENIC STEROIDS  (MAYO),1883582,CDM,300,RC,83582,HCPCS,Outpatient,,,113.25,67.95,,96.26,85,,77.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.63,80.03,,72.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,101.93,90,,81.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.66,88,,79.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.82,101.93,
MYCOBACTERIA  SEQUENCING ID  (MAYO),1887154,CDM,300,RC,87153,HCPCS,Outpatient,,,113.25,67.95,,96.26,85,,77.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.41,32.15,,29.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.63,80.03,,72.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,117.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,101.93,90,,81.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.41,32.15,,29.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,36.41,32.15,,29.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.66,88,,79.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.5,33.11,,30,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.41,101.93,
ACAPELLA DM-BLUE,30337,CDM,270,RC,,,Outpatient,,,113.5,68.1,,96.48,85,,77.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.83,80.03,,72.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.15,90,,81.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.88,88,,79.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.58,33.11,,30.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.49,102.15,
ACAPELLA DM-GREEN,30338,CDM,270,RC,,,Outpatient,,,113.5,68.1,,96.48,85,,77.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.83,80.03,,72.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.15,90,,81.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.88,88,,79.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.58,33.11,,30.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.49,102.15,
"PLATELET NEUTRALIZATION, dRVVT  (MAYO)",1885732,CDM,300,RC,85597,HCPCS,Outpatient,,,113.5,68.1,,96.48,85,,77.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.83,80.03,,72.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,102.15,90,,81.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.88,88,,79.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.61,102.15,
DIPTHERIA/TETANUS ANTIBODY PANEL (MAYO),1886648,CDM,300,RC,86648,HCPCS,Outpatient,,,113.5,68.1,,96.48,85,,77.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,90.83,80.03,,72.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,102.15,90,,81.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.88,88,,79.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.13,102.15,
STERILE WHIRLPOOL: LARGE TANK,330,CDM,420,RC,97022,HCPCS,Outpatient,,,113.5,68.1,,96.48,85,,77.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.83,80.03,,72.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,102.15,90,,81.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,36.49,32.15,,29.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.88,88,,79.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.58,33.11,,30.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.49,102.15,
STETHOSCOPE DISPOSABLE,493100,CDM,270,RC,,,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
FIBROSURE NEPHELOMETRY NOT SPEC  (MAYO),1883882,CDM,300,RC,83883,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.87,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.87,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.1,102.38,
"ELECTROPHERESIS PROTEIN, URINE 24 (MAYO)",1884190,CDM,300,RC,84166,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.43,102.38,
"IMMUNOFIXATION, U  (MAYO)",1884191,CDM,300,RC,84166,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.43,102.38,
"ELECTRO PRO, BODY FLUID  (MAYO)",1884201,CDM,300,RC,84166,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.43,102.38,
P/T HOME CARE,3975,CDM,420,RC,97537,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.95,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.95,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
"P/T ORTH/PROS, SUB, EA 15 MIN",3197763,CDM,420,RC,97763,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,50.43,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.43,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
Occupational therapy,365,CDM,430,RC,97535,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
Manipulation of 1 or more regions of the body,5997140,CDM,430,RC,97140,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); each separate/additional lesion",11103,CDM,761,RC,11103,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
PUNCH BIOPSY OF SKIN-EA  ADD LESION,11105,CDM,761,RC,11105,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
INCISIONAL BIOPSY OF SKIN-EA  ADD LESION,11107,CDM,761,RC,11107,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
CATH THORACIC 24FR STRAIGHT,49604,CDM,270,RC,,,Outpatient,,,114,68.4,,96.9,85,,77.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.65,32.15,,29.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.23,80.03,,72.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.6,90,,82.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.65,32.15,,29.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.65,32.15,,29.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.32,88,,80.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.75,33.11,,30.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.65,102.6,
NEEDLE TEGRESS STAINLESS STEELE,4999004,CDM,270,RC,,,Outpatient,,,114.25,68.55,,97.11,85,,77.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.73,32.15,,29.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.43,80.03,,73.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.83,90,,82.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.73,32.15,,29.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.73,32.15,,29.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.54,88,,80.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.83,33.11,,30.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.73,102.83,
DISOPYRAMIDE LEVEL  (MAYO),1882663,CDM,300,RC,83520,HCPCS,Outpatient,,,114.25,68.55,,97.11,85,,77.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.43,80.03,,73.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,102.83,90,,82.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.54,88,,80.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,102.83,
NM IODINE 123-200 UCI KIT,2932296,CDM,255,RC,A4641,HCPCS,Outpatient,,,114.33,68.6,,97.18,85,,77.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.76,32.15,,29.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.5,80.03,,73.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.9,90,,82.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.76,32.15,,29.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.76,32.15,,29.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.61,88,,80.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.85,33.11,,30.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.76,102.9,
EPOGEN (EPOETIN)*DIALYSIS: 4000 UNIT INJ,293082,CDM,636,RC,Q4081,HCPCS,Outpatient,,,114.33,68.6,,97.18,85,,77.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.5,80.03,,73.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.9,90,,82.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.61,88,,80.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.71,102.9,
CATH FOLEY 18FR 5CC 3-WAY,49512,CDM,270,RC,,,Outpatient,,,114.5,68.7,,97.33,85,,77.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.81,32.15,,29.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.63,80.03,,73.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.05,90,,82.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.81,32.15,,29.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.81,32.15,,29.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.76,88,,80.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.91,33.11,,30.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.81,103.05,
CATH FOLEY 22FR 5CC 3-WAY,49525,CDM,270,RC,,,Outpatient,,,114.5,68.7,,97.33,85,,77.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.81,32.15,,29.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.63,80.03,,73.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.05,90,,82.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.81,32.15,,29.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.81,32.15,,29.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.76,88,,80.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.91,33.11,,30.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.81,103.05,
Blood test to measure B-12,1884914,CDM,300,RC,82607,HCPCS,Outpatient,,,114.7,68.82,,97.5,85,,78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,91.79,80.03,,73.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,103.23,90,,82.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.94,88,,80.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,103.23,
AZACTAM  (aztreonam) 1GM / NS 50ML PB,293019,CDM,250,RC,S0073,HCPCS,Outpatient,,,114.8,68.88,,97.58,85,,78.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.91,32.15,,29.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.87,80.03,,73.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.32,90,,82.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.91,32.15,,29.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.91,32.15,,29.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.02,88,,80.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.01,33.11,,30.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.91,103.32,
AEROBID-M INHALER,292058,CDM,250,RC,,,Outpatient,,,114.85,68.91,,97.62,85,,78.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.92,32.15,,29.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.91,80.03,,73.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.37,90,,82.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.92,32.15,,29.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.92,32.15,,29.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.07,88,,80.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.03,33.11,,30.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.92,103.37,
CLINDESSE 2% VAG CREAM 5.8G,296096,CDM,250,RC,,,Outpatient,,,115,69,,97.75,85,,78.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.03,80.03,,73.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,90,,82.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.2,88,,80.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.08,33.11,,30.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.97,103.5,
WARM & FORM BRACE,31303,CDM,270,RC,,,Outpatient,,,115,69,,97.75,85,,78.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.03,80.03,,73.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,90,,82.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.2,88,,80.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.08,33.11,,30.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.97,103.5,
ORG-REFERRED FOR ID-ANAER,1887075,CDM,300,RC,,,Outpatient,,,115,69,,97.75,85,,78.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.03,80.03,,73.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,90,,82.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.2,88,,80.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.08,33.11,,30.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.97,103.5,
SEMEN ANALYSIS (TOTAL),1889310,CDM,300,RC,89322,HCPCS,Outpatient,,,115,69,,97.75,85,,78.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.03,80.03,,73.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,103.5,90,,82.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.2,88,,80.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.51,103.5,
Radiologic examination of the pelvis,22044,CDM,320,RC,72170,HCPCS,Outpatient,,,115,69,,97.75,85,,78.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.03,80.03,,73.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,103.5,90,,82.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.2,88,,80.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.08,33.11,,30.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.97,103.5,
Manipulation of 1 or more regions of the body,3110018,CDM,420,RC,97140,HCPCS,Outpatient,,,115,69,,97.75,85,,78.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.03,80.03,,73.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,103.5,90,,82.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.2,88,,80.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.08,33.11,,30.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.97,103.5,
Outpatient visit of established patient requiring a physician,4007,CDM,761,RC,99212,HCPCS,Outpatient,,,115,69,,97.75,85,,78.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.03,80.03,,73.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,90,,82.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.97,32.15,,29.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.2,88,,80.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.08,33.11,,30.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.97,103.5,
SUPPORTER XL ATHLETIC ADULT 44 -50,493353,CDM,270,RC,,,Outpatient,,,115.25,69.15,,97.96,85,,78.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.05,32.15,,29.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.23,80.03,,73.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.73,90,,82.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.05,32.15,,29.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.05,32.15,,29.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.42,88,,81.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.16,33.11,,30.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.05,103.73,
DRUG SCREEN AMPHETAMINES (MAYO),1882646,CDM,300,RC,80324,HCPCS,Outpatient,,,115.25,69.15,,97.96,85,,78.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.23,80.03,,73.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.73,90,,82.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.42,88,,81.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.55,103.73,
FACTOR VIII  (MAYO),1885240,CDM,300,RC,85250,HCPCS,Outpatient,,,115.25,69.15,,97.96,85,,78.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.23,80.03,,73.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,103.73,90,,82.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.42,88,,81.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.94,103.73,
FACTOR IX  ACTIVITY  (MAYO),1885251,CDM,300,RC,85250,HCPCS,Outpatient,,,115.25,69.15,,97.96,85,,78.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.23,80.03,,73.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,103.73,90,,82.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.42,88,,81.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.94,103.73,
PLATELET WBC REMOVAL FILTER,20005,CDM,270,RC,,,Outpatient,,,115.5,69.3,,98.18,85,,78.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.13,32.15,,29.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.43,80.03,,73.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.95,90,,83.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.13,32.15,,29.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.13,32.15,,29.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.64,88,,81.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.24,33.11,,30.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.13,103.95,
"HISTAMINE, WHOLE BLOOD   (MAYO)",1883087,CDM,300,RC,83088,HCPCS,Outpatient,,,115.5,69.3,,98.18,85,,78.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.43,80.03,,73.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,103.95,90,,83.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.64,88,,81.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.13,103.95,
STOCKINETTE IMPERVIOUS 12X48 STERILE LG,499821,CDM,270,RC,,,Outpatient,,,115.63,69.38,,98.29,85,,78.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.18,32.15,,29.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.54,80.03,,74.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.07,90,,83.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.18,32.15,,29.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.18,32.15,,29.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.75,88,,81.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.29,33.11,,30.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.18,104.07,
CATH THORACIC 20FR STRAIGHT 20,49918,CDM,270,RC,,,Outpatient,,,115.75,69.45,,98.39,85,,78.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.21,32.15,,29.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.63,80.03,,74.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.18,90,,83.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.21,32.15,,29.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.21,32.15,,29.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.86,88,,81.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.32,33.11,,30.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.21,104.18,
DIAG LARYNOSCOPY,9036,CDM,360,RC,,,Outpatient,,,115.75,69.45,,98.39,85,,78.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.21,32.15,,29.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.63,80.03,,74.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.18,90,,83.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.21,32.15,,29.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.21,32.15,,29.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.86,88,,81.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.32,33.11,,30.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.21,104.18,
STATE LAB/SCREENING NEWBORN,6009,CDM,300,RC,S3620,HCPCS,Outpatient,,,115.83,69.5,,98.46,85,,78.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.24,32.15,,29.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.7,80.03,,74.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.25,90,,83.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.24,32.15,,29.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.24,32.15,,29.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.93,88,,81.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.35,33.11,,30.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.24,104.25,
CUFF ADULT 2/T W/BULB BLOOD PRESSURE,493101,CDM,270,RC,,,Outpatient,,,116,69.6,,98.6,85,,78.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.29,32.15,,29.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,92.83,80.03,,74.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.4,90,,83.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.29,32.15,,29.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.29,32.15,,29.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.08,88,,81.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.41,33.11,,30.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.29,104.4,
Blood test to screen for antibodies that could harm red blood cells,2086006,CDM,300,RC,86850,HCPCS,Outpatient,,,116,69.6,,98.6,85,,78.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,92.83,80.03,,74.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,104.4,90,,83.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,15.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.08,88,,81.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.23,104.4,
DRESSING DUODERM SIGNAL 5 X 5,493262,CDM,270,RC,,,Outpatient,,,116.25,69.75,,98.81,85,,79.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.37,32.15,,29.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.03,80.03,,74.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.63,90,,83.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.37,32.15,,29.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.37,32.15,,29.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.3,88,,81.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.49,33.11,,30.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.37,104.63,
"DRAPE, LAPAROTOMY, T, PEDI, STERILE",499241,CDM,270,RC,,,Outpatient,,,116.25,69.75,,98.81,85,,79.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.37,32.15,,29.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.03,80.03,,74.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.63,90,,83.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.37,32.15,,29.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.37,32.15,,29.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.3,88,,81.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.49,33.11,,30.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.37,104.63,
..CHLAMYDIA AG,1887151,CDM,300,RC,86631,HCPCS,Outpatient,,,116.25,69.75,,98.81,85,,79.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.03,80.03,,74.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.05,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,104.63,90,,83.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.05,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.3,88,,81.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.87,104.63,
FLU VACCINE *HI-DOSE* (influenza) 0.5ML,293564,CDM,636,RC,90653,HCPCS,Outpatient,,,116.37,69.82,,98.91,85,,79.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.41,32.15,,29.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.13,80.03,,74.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.73,90,,83.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.41,32.15,,29.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.41,32.15,,29.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.41,88,,81.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.53,33.11,,30.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.41,104.73,
DOBUTREX (dobutamine) : 250MG INJ,293073,CDM,636,RC,J1250,HCPCS,Outpatient,,,116.39,69.83,,98.93,85,,79.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.15,80.03,,74.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.75,90,,83.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.42,88,,81.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.82,104.75,
LOVENOX (enoxaparin) : 100MG INJ,293442,CDM,250,RC,,,Outpatient,,,116.45,69.87,,98.98,85,,79.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.44,32.15,,29.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.19,80.03,,74.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.81,90,,83.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.44,32.15,,29.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.44,32.15,,29.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.48,88,,81.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.56,33.11,,30.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.44,104.81,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,9392252,CDM,921,RC,93922,HCPCS,Outpatient,,,116.5,69.9,,99.03,85,,79.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.45,32.15,,29.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.23,80.03,,74.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,104.85,90,,83.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.45,32.15,,29.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,37.45,32.15,,29.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.52,88,,82.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.57,33.11,,30.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.45,104.85,
DRESSING KALTOSTAT WOUND 5.6  X 9.5,491518,CDM,270,RC,,,Outpatient,,,116.75,70.05,,99.24,85,,79.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.54,32.15,,30.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.44,80.03,,74.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.08,90,,84.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.54,32.15,,30.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.54,32.15,,30.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.74,88,,82.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.66,33.11,,30.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.54,105.08,
"ACETYLCHOLINESTERASE, RBC  (MAYO)",1882481,CDM,300,RC,82482,HCPCS,Outpatient,,,116.75,70.05,,99.24,85,,79.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.44,80.03,,74.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,105.08,90,,84.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.74,88,,82.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.67,105.08,
NM SULFUR COLLOID,2932283,CDM,343,RC,A9541,HCPCS,Outpatient,,,116.91,70.15,,99.37,85,,79.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.59,32.15,,30.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.56,80.03,,74.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.22,90,,84.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.59,32.15,,30.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.59,32.15,,30.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.88,88,,82.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.71,33.11,,30.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.59,105.22,
Blood test to screen for syphilis,1884910,CDM,300,RC,86592,HCPCS,Outpatient,,,117,70.2,,99.45,85,,79.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.64,80.03,,74.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,105.3,90,,84.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,4.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.96,88,,82.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.65,105.3,
MYCOBACTERIUM ID REFLEX  (MAYO),1887153,CDM,300,RC,87153,HCPCS,Outpatient,,,117,70.2,,99.45,85,,79.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.62,32.15,,30.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.64,80.03,,74.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,117.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,105.3,90,,84.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.62,32.15,,30.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,37.62,32.15,,30.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.96,88,,82.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.74,33.11,,30.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.62,105.3,
OP OBSERVATION ICU,15003,CDM,762,RC,99218,HCPCS,Outpatient,,,117.19,70.31,,99.61,85,,79.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.68,32.15,,30.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.79,80.03,,75.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.47,90,,84.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.68,32.15,,30.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.68,32.15,,30.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.13,88,,82.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.8,33.11,,31.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.68,105.47,
Test to predict likelihood of gestational diabetes,1882953,CDM,300,RC,82951,HCPCS,Outpatient,,,117.25,70.35,,99.66,85,,79.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.84,80.03,,75.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,105.53,90,,84.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.18,88,,82.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,105.53,
Radiologic examination of the finger(s),22278,CDM,320,RC,73140,HCPCS,Outpatient,,,117.25,70.35,,99.66,85,,79.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.7,32.15,,30.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.84,80.03,,75.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,105.53,90,,84.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.7,32.15,,30.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,37.7,32.15,,30.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.18,88,,82.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.82,33.11,,31.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.7,105.53,
PAP smear,2188394,CDM,300,RC,88142,HCPCS,Outpatient,,,117.5,70.5,,99.88,85,,79.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.04,80.03,,75.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,105.75,90,,84.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,25.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.4,88,,82.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.48,105.75,
CATHETER INFECTION CTRL 3 WAY 30CC 22FR,49470,CDM,270,RC,,,Outpatient,,,117.75,70.65,,100.09,85,,80.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.24,80.03,,75.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.98,90,,84.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.62,88,,82.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.99,33.11,,31.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.86,105.98,
WAFFER SUR-FIT FLEXIBLE 1 3/4,493221,CDM,270,RC,,,Outpatient,,,117.75,70.65,,100.09,85,,80.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.24,80.03,,75.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.98,90,,84.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.62,88,,82.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.99,33.11,,31.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.86,105.98,
SET EXTENSION HIGH VOLUME FLOW,496504,CDM,270,RC,,,Outpatient,,,117.75,70.65,,100.09,85,,80.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.24,80.03,,75.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.98,90,,84.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.86,32.15,,30.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.62,88,,82.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.99,33.11,,31.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.86,105.98,
PRO-INSULIN  (MAYO),1884206,CDM,300,RC,84206,HCPCS,Outpatient,,,117.75,70.65,,100.09,85,,80.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.24,80.03,,75.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,105.98,90,,84.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.62,88,,82.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.4,105.98,
"TOXIGENIC E. COLI  AG, FECES  (MAYO)",1887427,CDM,300,RC,87427,HCPCS,Outpatient,,,117.75,70.65,,100.09,85,,80.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.24,80.03,,75.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.21,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,105.98,90,,84.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.21,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.62,88,,82.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,105.98,
"FLOW CYTO, 2-8 MARKERS INTERP",2188369,CDM,300,RC,88187,HCPCS,Outpatient,,,117.75,70.65,,100.09,85,,80.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.24,80.03,,75.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.98,90,,84.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,59.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.62,88,,82.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,59.78,105.98,
FACTOR VII ASSAY  (MAYO),1885212,CDM,300,RC,85230,HCPCS,Outpatient,,,118,70.8,,100.3,85,,80.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.44,80.03,,75.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,106.2,90,,84.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.84,88,,83.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.52,106.2,
URINE BICARBONATE  (MAYO),1882373,CDM,300,RC,82374,HCPCS,Outpatient,,,118.25,70.95,,100.51,85,,80.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.64,80.03,,75.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.97,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,106.43,90,,85.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.97,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.06,88,,83.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.15,106.43,
"DEMEROL, MEPERIDINE  (MAYO)",1883927,CDM,300,RC,80362,HCPCS,Outpatient,,,118.25,70.95,,100.51,85,,80.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.64,80.03,,75.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.43,90,,85.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.06,88,,83.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.47,106.43,
"OXYCODONE, SERUM   (MAYO)",1880105,CDM,300,RC,80365,HCPCS,Outpatient,,,118.5,71.1,,100.73,85,,80.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.84,80.03,,75.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.65,90,,85.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.28,88,,83.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.24,33.11,,31.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.1,106.65,
FACTOR II ASSAY  (MAYO),1885209,CDM,300,RC,85210,HCPCS,Outpatient,,,118.5,71.1,,100.73,85,,80.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.84,80.03,,75.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.23,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,106.65,90,,85.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.23,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.28,88,,83.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.33,106.65,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,394,CDM,420,RC,97033,HCPCS,Outpatient,,,118.5,71.1,,100.73,85,,80.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.84,80.03,,75.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,106.65,90,,85.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.28,88,,83.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.24,33.11,,31.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.1,106.65,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,395,CDM,430,RC,97033,HCPCS,Outpatient,,,118.5,71.1,,100.73,85,,80.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.84,80.03,,75.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,106.65,90,,85.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.1,32.15,,30.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.28,88,,83.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.24,33.11,,31.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.1,106.65,
"CORTISOL, SERUM (MAYO)",1882533,CDM,300,RC,82533,HCPCS,Outpatient,,,118.59,71.15,,100.8,85,,80.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,94.91,80.03,,75.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,106.73,90,,85.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.36,88,,83.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.12,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.5,106.73,
IMMOBILIZER SHOULDER X-LARGE VELPEAU,491153,CDM,270,RC,,,Outpatient,,,118.75,71.25,,100.94,85,,80.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,80.03,,76.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.88,90,,85.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.5,88,,83.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.32,33.11,,31.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.18,106.88,
IMMOBILIZER SHOULDER SMALL VELPEAU,491154,CDM,270,RC,,,Outpatient,,,118.75,71.25,,100.94,85,,80.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,80.03,,76.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.88,90,,85.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.5,88,,83.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.32,33.11,,31.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.18,106.88,
IMMOBILIZER SHOULDER XX-LARGE VELPEAU,491157,CDM,270,RC,,,Outpatient,,,118.75,71.25,,100.94,85,,80.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,80.03,,76.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.88,90,,85.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.18,32.15,,30.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.5,88,,83.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.32,33.11,,31.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.18,106.88,
EASTERN EQUINE ENCEPHALITIS AB  (MAYO),1886653,CDM,300,RC,86652,HCPCS,Outpatient,,,119,71.4,,101.15,85,,80.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.24,80.03,,76.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,107.1,90,,85.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.72,88,,83.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.59,107.1,
Blood test to measure B-12,1882607,CDM,300,RC,82607,HCPCS,Outpatient,,,119.17,71.5,,101.29,85,,81.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.37,80.03,,76.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,107.25,90,,85.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.87,88,,83.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,107.25,
FOLATE (MAYO),1882746,CDM,300,RC,82746,HCPCS,Outpatient,,,119.17,71.5,,101.29,85,,81.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.37,80.03,,76.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,107.25,90,,85.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.87,88,,83.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.49,107.25,
ROCEPHIN (ceftriaxone) : variable ds 1g,293535,CDM,636,RC,J0696,HCPCS,Outpatient,,,119.23,71.54,,101.35,85,,81.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.42,80.03,,76.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.31,90,,85.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.92,88,,83.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.47,107.31,
ROCEPHIN (ceftriaxone) Wt-based dose,295003,CDM,636,RC,J0696,HCPCS,Outpatient,,,119.23,71.54,,101.35,85,,81.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.42,80.03,,76.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.31,90,,85.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.92,88,,83.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.47,107.31,
PROVENTIL INHALER,532046,CDM,250,RC,,,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.57,33.11,,31.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.42,107.55,
".OXIMETER PROBER, DISPOSABLE",30374,CDM,270,RC,,,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.57,33.11,,31.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.42,107.55,
DRAIN INCISE 15 1/2 X 15 1/2,49976,CDM,270,RC,,,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.57,33.11,,31.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.42,107.55,
ELECTRO SURGICAL UNIT,97025,CDM,270,RC,,,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.57,33.11,,31.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.42,107.55,
BINDER ABDOMINAL 9  46-62 INCH,491148,CDM,270,RC,,,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.57,33.11,,31.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.42,107.55,
PRESSURE INFUSER 500ML,496532,CDM,270,RC,,,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.57,33.11,,31.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.42,107.55,
Blood test to assist with diagnosis,2185535,CDM,300,RC,88313,HCPCS,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,107.55,
DECALCIFICATION,2188311,CDM,310,RC,88311,HCPCS,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.45,107.55,
THORACENTESIS,3007,CDM,761,RC,32000,HCPCS,Outpatient,,,119.5,71.7,,101.58,85,,81.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.64,80.03,,76.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.55,90,,86.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.42,32.15,,30.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.16,88,,84.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.57,33.11,,31.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.42,107.55,
Immunization administration by a medical assistant or nurse,290086,CDM,771,RC,90471,HCPCS,Outpatient,,,119.72,71.83,,101.76,85,,81.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.49,32.15,,30.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.81,80.03,,76.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,107.75,90,,86.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.49,32.15,,30.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,38.49,32.15,,30.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.35,88,,84.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.64,33.11,,31.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.49,107.75,
ADHESIVE MEDICAL STERILE,4999922,CDM,270,RC,,,Outpatient,,,119.75,71.85,,101.79,85,,81.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.5,32.15,,30.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.84,80.03,,76.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.78,90,,86.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.5,32.15,,30.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.5,32.15,,30.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.38,88,,84.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.65,33.11,,31.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.5,107.78,
SEX HORMONE BINDING GLOBULIN  (MAYO),1884808,CDM,300,RC,84270,HCPCS,Outpatient,,,119.75,71.85,,101.79,85,,81.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,95.84,80.03,,76.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,107.78,90,,86.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.38,88,,84.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.32,107.78,
CARBOHYDRATE DEF TRANSFERRIN  (MAYO),1884685,CDM,300,RC,82373,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,108,
"BLASTOMYCES AB EIA, SERUM (MAYO)",1886333,CDM,300,RC,86612,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.23,108,
"T CELLS, TOTAL COUNT  (MAYO)",1886357,CDM,300,RC,86359,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,38.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,29.62,108,
"ENTEROVIRUS, VARIOUS SOURCE  PCR  (MAYO)",1887498,CDM,300,RC,87498,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,108,
"ENTEROVIRUS, PLASMA  (MAYO)",1887499,CDM,300,RC,87498,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,108,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",341,CDM,420,RC,97110,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
A technique used by physical therapists to restore normal body movement patterns,345,CDM,420,RC,97112,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
Manipulation of 1 or more regions of the body,356,CDM,420,RC,97140,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
W/C MOBILITY IV,374,CDM,420,RC,97542,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.95,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30.95,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
INPATIENT TRACTION ASSEMBLY IV,385,CDM,420,RC,97139,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
DO NOT USE,311003,CDM,420,RC,97750,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
P/T HOME PROGRAM,311028,CDM,420,RC,97139,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",311031,CDM,420,RC,97110,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
A technique used by physical therapists to restore normal body movement patterns,311109,CDM,420,RC,97112,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
P/T STERILE WHIRLPOOL I,311202,CDM,420,RC,97022,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
P/T REASSESSMENT,3100005,CDM,420,RC,97002,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
A technique used by physical therapists to restore normal body movement patterns,3197112,CDM,420,RC,97112,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
Occupational therapy,368,CDM,430,RC,97535,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",3411,CDM,430,RC,97110,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
A technique used by physical therapists to restore normal body movement patterns,3451,CDM,430,RC,97112,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
O/T MYOFASCIAL RELEASE IV,3561,CDM,430,RC,97250,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120,,,,Other,Not Separately reimbursable,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
O/T HOME EXERCISE PROGRAM,59004,CDM,430,RC,97139,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
LEVAQUIN  (levofloxacin) 500MG /100ML PB,293036,CDM,636,RC,J1956,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
ROCEPHIN (ceftriaxone) 1GM /SW 10ML PB,293328,CDM,636,RC,J0696,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.47,108,
LEVAQUIN  (levofloxacin) 750MG /150ML PB,293825,CDM,636,RC,J1956,HCPCS,Outpatient,,,120,72,,102,85,,81.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.04,80.03,,76.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,90,,86.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.58,32.15,,30.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.6,88,,84.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.73,33.11,,31.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.58,108,
LEVAQUIN  (levofloxacin) 250MG / 50ML PB,293498,CDM,636,RC,J1956,HCPCS,Outpatient,,,120.25,72.15,,102.21,85,,81.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.66,32.15,,30.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.24,80.03,,76.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.23,90,,86.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.66,32.15,,30.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.66,32.15,,30.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.82,88,,84.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.81,33.11,,31.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.66,108.23,
NM MAA,2932284,CDM,343,RC,A9540,HCPCS,Outpatient,,,120.26,72.16,,102.22,85,,81.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.66,32.15,,30.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.24,80.03,,76.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.23,90,,86.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.66,32.15,,30.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.66,32.15,,30.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.83,88,,84.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.82,33.11,,31.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.66,108.23,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",4021,CDM,260,RC,96375,HCPCS,Outpatient,,,120.31,72.19,,102.26,85,,81.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.68,32.15,,30.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.28,80.03,,77.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,108.28,90,,86.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.68,32.15,,30.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,38.68,32.15,,30.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.87,88,,84.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.83,33.11,,31.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.68,108.28,
CAM WALKER; MEDIUM,314045,CDM,270,RC,,,Outpatient,,,120.5,72.3,,102.43,85,,81.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.74,32.15,,30.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.44,80.03,,77.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.45,90,,86.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.74,32.15,,30.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.74,32.15,,30.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.04,88,,84.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.9,33.11,,31.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.74,108.45,
Test that detects Chlamydia,1884897,CDM,300,RC,87491,HCPCS,Outpatient,,,120.53,72.32,,102.45,85,,81.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.46,80.03,,77.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,108.48,90,,86.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.07,88,,84.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,108.48,
SLING ARM SMALL,491219,CDM,270,RC,,,Outpatient,,,120.75,72.45,,102.64,85,,82.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.82,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.64,80.03,,77.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.68,90,,86.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.82,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.82,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.26,88,,85.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.98,33.11,,31.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.82,108.68,
TRYPTASE  (MAYO),1883529,CDM,300,RC,83520,HCPCS,Outpatient,,,120.75,72.45,,102.64,85,,82.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.64,80.03,,77.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,108.68,90,,86.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.26,88,,85.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,108.68,
S/T SWALLOWING REASSESSMENT,322020,CDM,440,RC,92610,HCPCS,Outpatient,,,120.75,72.45,,102.64,85,,82.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.82,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.64,80.03,,77.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,68.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,108.68,90,,86.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.82,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,38.82,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.26,88,,85.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.98,33.11,,31.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.82,108.68,
FORTAZ (ceftazidime) 2GM /NS 50ML PB,293321,CDM,636,RC,J0713,HCPCS,Outpatient,,,120.77,72.46,,102.65,85,,82.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.65,80.03,,77.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.69,90,,86.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.28,88,,85.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.78,108.69,
FORTAZ (ceftazidime) : 2GM VIAL,293357,CDM,636,RC,J0713,HCPCS,Outpatient,,,120.77,72.46,,102.65,85,,82.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,96.65,80.03,,77.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.69,90,,86.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,1.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.28,88,,85.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1.78,108.69,
MAXIPIME (CEFEPIME) : 2GM VIAL,393876,CDM,636,RC,J0692,HCPCS,Outpatient,,,120.77,72.46,,102.65,85,,82.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.83,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.65,80.03,,77.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.69,90,,86.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.83,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.83,32.15,,31.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.28,88,,85.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.99,33.11,,31.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.83,108.69,
LUMBO SCRAL SUPPORT #48,312000,CDM,270,RC,,,Outpatient,,,120.8,72.48,,102.68,85,,82.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.84,32.15,,31.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.68,80.03,,77.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.72,90,,86.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.84,32.15,,31.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.84,32.15,,31.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.3,88,,85.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40,33.11,,32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.84,108.72,
"2 views, front and back",22555,CDM,320,RC,71046,HCPCS,Outpatient,,,121,72.6,,102.85,85,,82.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.9,32.15,,31.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.84,80.03,,77.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,108.9,90,,87.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.9,32.15,,31.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,38.9,32.15,,31.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.48,88,,85.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.06,33.11,,32.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.9,108.9,
"AMINOLEVULINIC ACID (ALA), URINE  (MAYO)",1882135,CDM,300,RC,82135,HCPCS,Outpatient,,,121.25,72.75,,103.06,85,,82.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.04,80.03,,77.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,109.13,90,,87.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.7,88,,85.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.7,109.13,
"AMINOLEVULINIC ACID, URINE  (MAYO)",1882666,CDM,300,RC,82135,HCPCS,Outpatient,,,121.25,72.75,,103.06,85,,82.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.04,80.03,,77.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,109.13,90,,87.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.7,88,,85.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.7,109.13,
O/T FINGER BUDDY STRAP,3948,CDM,430,RC,L3948,HCPCS,Outpatient,,,121.5,72.9,,103.28,85,,82.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.06,32.15,,31.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.24,80.03,,77.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.35,90,,87.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.06,32.15,,31.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.06,32.15,,31.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.92,88,,85.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.23,33.11,,32.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.06,109.35,
S/T SPEECH GROUP ACTIVITY,322006,CDM,440,RC,92508,HCPCS,Outpatient,,,121.5,72.9,,103.28,85,,82.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.06,32.15,,31.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.24,80.03,,77.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.02,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,109.35,90,,87.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.06,32.15,,31.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.02,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,39.06,32.15,,31.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.92,88,,85.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.23,33.11,,32.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.06,109.35,
Manipulation of 1 or more regions of the body,3197140,CDM,420,RC,97140,HCPCS,Outpatient,,,121.56,72.94,,103.33,85,,82.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.08,32.15,,31.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.28,80.03,,77.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,109.4,90,,87.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.08,32.15,,31.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,39.08,32.15,,31.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.97,88,,85.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.25,33.11,,32.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.08,109.4,
Test for HIV,1886304,CDM,300,RC,87389,HCPCS,Outpatient,,,121.75,73.05,,103.49,85,,82.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.44,80.03,,77.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,109.58,90,,87.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.14,88,,85.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.12,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.3,109.58,
SUPREP (bowel prep kit) ORAL SOLN 2X 6OZ,295674,CDM,250,RC,,,Outpatient,,,122,73.2,,103.7,85,,82.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.64,80.03,,78.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.8,90,,87.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.36,88,,85.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.39,33.11,,32.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.22,109.8,
DRAPE UROLOGICAL FINGER INVISISHIELD,49980,CDM,270,RC,,,Outpatient,,,122,73.2,,103.7,85,,82.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.64,80.03,,78.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.8,90,,87.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.36,88,,85.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.39,33.11,,32.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.22,109.8,
AMINO ACID SCREEN QL(PLASMA)  (MAYO),1882109,CDM,300,RC,82128,HCPCS,Outpatient,,,122,73.2,,103.7,85,,82.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.64,80.03,,78.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.14,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,109.8,90,,87.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.14,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.36,88,,85.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.43,109.8,
RBC SEPERATION (TBC),1887813,CDM,300,RC,85999,HCPCS,Outpatient,,,122,73.2,,103.7,85,,82.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.64,80.03,,78.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.8,90,,87.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.22,32.15,,31.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.36,88,,85.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.39,33.11,,32.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.22,109.8,
"TIAGABENE, GABITRIL  (MAYO)",1882487,CDM,300,RC,80199,HCPCS,Outpatient,,,122.25,73.35,,103.91,85,,83.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.84,80.03,,78.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.65,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,110.03,90,,88.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.65,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.58,88,,86.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.55,110.03,
"DRUG SCREEN 5, MECONIUM  (MAYO)",1882667,CDM,300,RC,80301,HCPCS,Outpatient,,,122.25,73.35,,103.91,85,,83.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.3,32.15,,31.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.84,80.03,,78.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.03,90,,88.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.3,32.15,,31.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.3,32.15,,31.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.58,88,,86.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.48,33.11,,32.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.3,110.03,
"DRUG SCREEN, QL, EACH",1882680,CDM,300,RC,80301,HCPCS,Outpatient,,,122.25,73.35,,103.91,85,,83.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.3,32.15,,31.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.84,80.03,,78.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.03,90,,88.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.3,32.15,,31.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.3,32.15,,31.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.58,88,,86.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.48,33.11,,32.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.3,110.03,
"GLUCOSE-6-PHOSPHATE DEHYD, QT  (MAYO)",1882960,CDM,300,RC,82955,HCPCS,Outpatient,,,122.25,73.35,,103.91,85,,83.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.84,80.03,,78.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,110.03,90,,88.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.58,88,,86.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.82,110.03,
"CMV, CSF (OTHER BODY FLUID)  (MAYO)",1887496,CDM,300,RC,87496,HCPCS,Outpatient,,,122.25,73.35,,103.91,85,,83.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.84,80.03,,78.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,110.03,90,,88.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.58,88,,86.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,110.03,
P/T WOUND EA ADDTNL 20CM2-ALL OR PART,3969,CDM,420,RC,97598,HCPCS,Outpatient,,,122.7,73.62,,104.3,85,,83.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.45,32.15,,31.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.2,80.03,,78.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.43,90,,88.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.45,32.15,,31.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.45,32.15,,31.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.98,88,,86.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.63,33.11,,32.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.45,110.43,
IV THERAPY HYDRATION ADDL HOUR,1496361,CDM,260,RC,96361,HCPCS,Outpatient,,,122.81,73.69,,104.39,85,,83.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.48,32.15,,31.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.28,80.03,,78.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,40.61,102,,,fee schedule,Pays at 102% of CMS APC rate,110.53,90,,88.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.48,32.15,,31.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.61,100,,,fee schedule,Pays at 100% of CMS APC rate,39.48,32.15,,31.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.07,88,,86.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.66,33.11,,32.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.48,110.53,
ALPHAGAN 0.1% (BRIMONIDINE) 5ML OPTH,297776,CDM,250,RC,,,Outpatient,,,123,73.8,,104.55,85,,83.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.44,80.03,,78.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,90,,88.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.24,88,,86.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.73,33.11,,32.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.54,110.7,
PROCTOCREAM HC 2.5% 1 OZ,298013,CDM,250,RC,,,Outpatient,,,123,73.8,,104.55,85,,83.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.44,80.03,,78.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,90,,88.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.24,88,,86.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.73,33.11,,32.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.54,110.7,
"TEMAZEPAM, RESTORIL   (MAYO)",1880155,CDM,300,RC,80154,HCPCS,Outpatient,,,123,73.8,,104.55,85,,83.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.44,80.03,,78.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,90,,88.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.54,32.15,,31.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.24,88,,86.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.73,33.11,,32.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.54,110.7,
AMB RESP & TREATMENT WITH NO TRANSPORT,530346,CDM,540,RC,A0998,HCPCS,Outpatient,,,123.15,73.89,,104.68,85,,83.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.59,32.15,,31.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.56,80.03,,78.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.84,90,,88.67,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.59,32.15,,31.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.59,32.15,,31.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.37,88,,86.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.77,33.11,,32.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.59,110.84,
"ADRENOCORTICOTROPIC HORMO, ACTH  (MAYO)",1882024,CDM,300,RC,82024,HCPCS,Outpatient,,,123.25,73.95,,104.76,85,,83.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.64,80.03,,78.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,39.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,110.93,90,,88.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,48.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.46,88,,86.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,48.57,110.93,
VITAMIN D 1-25 D-OH  (MAYO),1882652,CDM,300,RC,82652,HCPCS,Outpatient,,,123.25,73.95,,104.76,85,,83.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.64,80.03,,78.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,39.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,110.93,90,,88.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,48.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.46,88,,86.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,48.4,110.93,
"PLATELET NEUTRALIZATION, HEX  (MAYO)",1885214,CDM,300,RC,85598,HCPCS,Outpatient,,,123.25,73.95,,104.76,85,,83.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.64,80.03,,78.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,110.93,90,,88.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.46,88,,86.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.24,110.93,
"HIV-1 DNA, QL, PCR  (MAYO)",1887536,CDM,300,RC,87535,HCPCS,Outpatient,,,123.25,73.95,,104.76,85,,83.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.64,80.03,,78.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,110.93,90,,88.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.46,88,,86.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,110.93,
GYNAZOLE-1 (butoconazole) 2% CREAM 5GM,291085,CDM,250,RC,,,Outpatient,,,123.3,73.98,,104.81,85,,83.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.64,32.15,,31.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.68,80.03,,78.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.97,90,,88.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.64,32.15,,31.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.64,32.15,,31.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.5,88,,86.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.82,33.11,,32.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.64,110.97,
"DRESSING, VAC WHITE FOAM",43832,CDM,270,RC,,,Outpatient,,,123.75,74.25,,105.19,85,,84.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.79,32.15,,31.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.04,80.03,,79.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.38,90,,89.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.79,32.15,,31.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.79,32.15,,31.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.9,88,,87.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.97,33.11,,32.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.79,111.38,
S/T DYSPHAGIA TX,322029,CDM,440,RC,92526,HCPCS,Outpatient,,,123.75,74.25,,105.19,85,,84.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.79,32.15,,31.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.04,80.03,,79.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,82.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,111.38,90,,89.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.79,32.15,,31.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,39.79,32.15,,31.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.9,88,,87.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.97,33.11,,32.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.79,111.38,
IM INJECTION,4008,CDM,260,RC,96372,HCPCS,Outpatient,,,123.82,74.29,,105.25,85,,84.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.81,32.15,,31.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.09,80.03,,79.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,111.44,90,,89.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.81,32.15,,31.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,39.81,32.15,,31.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.96,88,,87.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41,33.11,,32.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.81,111.44,
SUBCUTANEOUS INJECTION,1490782,CDM,260,RC,96372,HCPCS,Outpatient,,,123.82,74.29,,105.25,85,,84.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.81,32.15,,31.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.09,80.03,,79.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,111.44,90,,89.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.81,32.15,,31.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,39.81,32.15,,31.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.96,88,,87.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41,33.11,,32.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.81,111.44,
P/T DRY WOUND,3902,CDM,420,RC,97799,HCPCS,Outpatient,,,123.9,74.34,,105.32,85,,84.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.83,32.15,,31.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.16,80.03,,79.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.51,90,,89.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.83,32.15,,31.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.83,32.15,,31.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.03,88,,87.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.02,33.11,,32.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.83,111.51,
KEFLEX (cephalexin) 250MG/5ML SUSP:200ML,294018,CDM,250,RC,,,Outpatient,,,124,74.4,,105.4,85,,84.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.24,80.03,,79.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.6,90,,89.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,88,,87.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.06,33.11,,32.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.87,111.6,
MASK NASAL MEDIUM/SHALLOW,491604,CDM,270,RC,,,Outpatient,,,124,74.4,,105.4,85,,84.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.24,80.03,,79.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.6,90,,89.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,88,,87.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.06,33.11,,32.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.87,111.6,
MASK NASAL MEDIUM/LARGE,491605,CDM,270,RC,,,Outpatient,,,124,74.4,,105.4,85,,84.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.24,80.03,,79.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.6,90,,89.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,88,,87.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.06,33.11,,32.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.87,111.6,
MASK NASAL LARGE,491606,CDM,270,RC,,,Outpatient,,,124,74.4,,105.4,85,,84.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.24,80.03,,79.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.6,90,,89.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,88,,87.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.06,33.11,,32.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.87,111.6,
HYPOGLYCEMIC AGENT SCREEN   MAYO,1880106,CDM,300,RC,,,Outpatient,,,124,74.4,,105.4,85,,84.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.24,80.03,,79.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.6,90,,89.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,88,,87.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.06,33.11,,32.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.87,111.6,
"..ENTEROVIRUS, CSF PCR  (MAYO)",1887252,CDM,300,RC,87798,HCPCS,Outpatient,,,124.2,74.52,,105.57,85,,84.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.4,80.03,,79.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,111.78,90,,89.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.3,88,,87.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,111.78,
BRACE KNEE SMALL,491182,CDM,270,RC,,,Outpatient,,,124.25,74.55,,105.61,85,,84.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.95,32.15,,31.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.44,80.03,,79.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.83,90,,89.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.95,32.15,,31.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.95,32.15,,31.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.34,88,,87.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.14,33.11,,32.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.95,111.83,
CADMIUM/CREATININE RATIO URINE  (MAYO),1883038,CDM,300,RC,82300,HCPCS,Outpatient,,,124.25,74.55,,105.61,85,,84.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.44,80.03,,79.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.11,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,111.83,90,,89.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.11,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,29.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.34,88,,87.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,29.1,111.83,
PROSTAGLANDIN  (MAYO),1884150,CDM,300,RC,84150,HCPCS,Outpatient,,,124.25,74.55,,105.61,85,,84.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.44,80.03,,79.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,42.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,111.83,90,,89.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.34,88,,87.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.39,111.83,
"ID MALDI-TOF MS, FUNGI  (MAYO)",1887111,CDM,300,RC,87107,HCPCS,Outpatient,,,124.25,74.55,,105.61,85,,84.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.44,80.03,,79.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,111.83,90,,89.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.34,88,,87.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,111.83,
"VITAMIN B3, NIACIN  (MAYO)",1884591,CDM,300,RC,84591,HCPCS,Outpatient,,,124.75,74.85,,106.04,85,,84.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.84,80.03,,79.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,112.28,90,,89.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.78,88,,87.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.58,112.28,
Acute hepatitis panel,1880059,CDM,300,RC,80074,HCPCS,Outpatient,,,124.85,74.91,,106.12,85,,84.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,99.92,80.03,,79.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.58,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,112.37,90,,89.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.58,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,59.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.87,88,,87.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,59.89,112.37,
EPIDURAL OB ROUTINE WITH NARCOTIC 250 ML,293524,CDM,250,RC,,,Outpatient,,,125,75,,106.25,85,,85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.19,32.15,,32.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.04,80.03,,80.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.5,90,,90,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.19,32.15,,32.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.19,32.15,,32.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110,88,,88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.39,33.11,,33.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.19,112.5,
CLINDAMYCIN VAG CREAM 2% 40GM 7 APPLIC,296097,CDM,250,RC,,,Outpatient,,,125,75,,106.25,85,,85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.19,32.15,,32.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.04,80.03,,80.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.5,90,,90,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.19,32.15,,32.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.19,32.15,,32.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110,88,,88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.39,33.11,,33.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.19,112.5,
ERYTHROMYCIN 1GM / NS 250ML,293081,CDM,636,RC,J1364,HCPCS,Outpatient,,,125,75,,106.25,85,,85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.04,80.03,,80.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,85.31,102,,,fee schedule,Pays at 102% of CMS APC rate,112.5,90,,90,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,85.31,100,,,fee schedule,Pays at 100% of CMS APC rate,83.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,110,88,,88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,86.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,83.64,112.5,
Hepatitis B vaccine,293291,CDM,636,RC,90746,HCPCS,Outpatient,,,125,75,,106.25,85,,85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.04,80.03,,80.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.5,90,,90,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,70.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,110,88,,88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,70.38,112.5,
RHO-GAM INJ 1 DOSE,293458,CDM,636,RC,J2790,HCPCS,Outpatient,,,125,75,,106.25,85,,85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.04,80.03,,80.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.5,90,,90,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,77.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,110,88,,88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.62,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,77.3,112.5,
"HOMOCYSTEINE, URINE  (MAYO)",1883090,CDM,300,RC,83090,HCPCS,Outpatient,,,125.25,75.15,,106.46,85,,85.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.24,80.03,,80.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,112.73,90,,90.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,110.22,88,,88.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.21,112.73,
X-ray of the hand with 2 views,22177,CDM,320,RC,73120,HCPCS,Outpatient,,,125.25,75.15,,106.46,85,,85.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.27,32.15,,32.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.24,80.03,,80.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,112.73,90,,90.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.27,32.15,,32.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,40.27,32.15,,32.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.22,88,,88.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.47,33.11,,33.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.27,112.73,
X-ray of the hand with 2 views,22282,CDM,320,RC,73120,HCPCS,Outpatient,,,125.25,75.15,,106.46,85,,85.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.27,32.15,,32.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.24,80.03,,80.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,112.73,90,,90.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.27,32.15,,32.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,40.27,32.15,,32.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.22,88,,88.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.47,33.11,,33.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.27,112.73,
WAFFER SUR-FIT FLEXIBLE 2 3/4,493205,CDM,270,RC,,,Outpatient,,,125.5,75.3,,106.68,85,,85.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.35,32.15,,32.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.44,80.03,,80.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.95,90,,90.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.35,32.15,,32.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.35,32.15,,32.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.44,88,,88.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.55,33.11,,33.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.35,112.95,
SUCTION WATERBUG,49035,CDM,270,RC,,,Outpatient,,,125.75,75.45,,106.89,85,,85.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.43,32.15,,32.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.64,80.03,,80.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.18,90,,90.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.43,32.15,,32.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.43,32.15,,32.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.66,88,,88.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.64,33.11,,33.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.43,113.18,
SPLINT WRIST LEFT-LARGE,491266,CDM,270,RC,,,Outpatient,,,126,75.6,,107.1,85,,85.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.84,80.03,,80.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,90.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.88,88,,88.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.72,33.11,,33.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.51,113.4,
SPLINT WRIST LEFT X-LARGE,491267,CDM,270,RC,,,Outpatient,,,126,75.6,,107.1,85,,85.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.84,80.03,,80.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,90.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.88,88,,88.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.72,33.11,,33.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.51,113.4,
SPLINT WRIST RIGHT MEDIUM,491284,CDM,270,RC,,,Outpatient,,,126,75.6,,107.1,85,,85.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.84,80.03,,80.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,90.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.88,88,,88.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.72,33.11,,33.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.51,113.4,
Mammography of both breasts-2 or more views,22122,CDM,403,RC,77067,HCPCS,Outpatient,,,126,75.6,,107.1,85,,85.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.84,80.03,,80.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,84.39,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,113.4,90,,90.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.39,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.88,88,,88.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.72,33.11,,33.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.51,113.4,
P/T HEAVY EXUDATE WOUNDS,3928,CDM,420,RC,97799,HCPCS,Outpatient,,,126,75.6,,107.1,85,,85.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.84,80.03,,80.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,90.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.51,32.15,,32.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.88,88,,88.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.72,33.11,,33.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.51,113.4,
SPLINT WRIST RIGHT X-LARGE,491270,CDM,270,RC,,,Outpatient,,,126.25,75.75,,107.31,85,,85.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.04,80.03,,80.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.63,90,,90.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.1,88,,88.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.8,33.11,,33.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.59,113.63,
SPLINT WRIST RIGHT LARGE,491272,CDM,270,RC,,,Outpatient,,,126.25,75.75,,107.31,85,,85.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.04,80.03,,80.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.63,90,,90.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.1,88,,88.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.8,33.11,,33.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.59,113.63,
SPLINT WRIST LEFT MEDIUM,491278,CDM,270,RC,,,Outpatient,,,126.25,75.75,,107.31,85,,85.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.04,80.03,,80.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.63,90,,90.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.1,88,,88.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.8,33.11,,33.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.59,113.63,
SPLINT WRIST LEFT SMALL,491290,CDM,270,RC,,,Outpatient,,,126.25,75.75,,107.31,85,,85.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.04,80.03,,80.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.63,90,,90.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.59,32.15,,32.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.1,88,,88.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.8,33.11,,33.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.59,113.63,
PROSTIN E2 (DINOPROSTONE) 20MG SUPP,296033,CDM,250,RC,,,Outpatient,,,126.44,75.86,,107.47,85,,85.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.65,32.15,,32.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.19,80.03,,80.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.8,90,,91.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.65,32.15,,32.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.65,32.15,,32.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.27,88,,89.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.86,33.11,,33.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.65,113.8,
KNEE COMPRESSION WRAP WITH GEL BAGS,4999985,CDM,270,RC,,,Outpatient,,,126.56,75.94,,107.58,85,,86.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.69,32.15,,32.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.29,80.03,,81.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.9,90,,91.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.69,32.15,,32.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.69,32.15,,32.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.37,88,,89.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.9,33.11,,33.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.69,113.9,
SOLU MEDROL (methylprednisolone)1000MG,293172,CDM,636,RC,J2930,HCPCS,Outpatient,,,126.67,76,,107.67,85,,86.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.37,80.03,,81.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,90,,91.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,4.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.47,88,,89.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.99,114,
PRED FORTE (PREDNISOLONE) 1% OPTH:5ML,297767,CDM,250,RC,,,Outpatient,,,126.72,76.03,,107.71,85,,86.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.74,32.15,,32.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.41,80.03,,81.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.05,90,,91.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.74,32.15,,32.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.74,32.15,,32.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.51,88,,89.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.96,33.11,,33.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.74,114.05,
PUREWICK FEMALE EXT CATH,49560,CDM,270,RC,,,Outpatient,,,126.9,76.14,,107.87,85,,86.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.8,32.15,,32.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.56,80.03,,81.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.21,90,,91.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.8,32.15,,32.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.8,32.15,,32.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.67,88,,89.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.02,33.11,,33.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.8,114.21,
PACK LAPAROSCOPY IV,498592,CDM,270,RC,,,Outpatient,,,127,76.2,,107.95,85,,86.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.83,32.15,,32.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.64,80.03,,81.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.3,90,,91.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.83,32.15,,32.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.83,32.15,,32.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.76,88,,89.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.05,33.11,,33.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.83,114.3,
AMPHETAMINES DRUG SCREEN 1/2 (MAYO),1882641,CDM,300,RC,80324,HCPCS,Outpatient,,,127,76.2,,107.95,85,,86.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.64,80.03,,81.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.3,90,,91.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.76,88,,89.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.55,114.3,
"WEST NILE VIRUS, CSF PCR  (MAYO)",1886791,CDM,300,RC,87798,HCPCS,Outpatient,,,127,76.2,,107.95,85,,86.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.64,80.03,,81.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,114.3,90,,91.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.76,88,,89.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,114.3,
BLANKET LOWER BODY,490009,CDM,270,RC,,,Outpatient,,,127.19,76.31,,108.11,85,,86.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.89,32.15,,32.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.79,80.03,,81.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.47,90,,91.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.89,32.15,,32.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.89,32.15,,32.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.93,88,,89.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.11,33.11,,33.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.89,114.47,
AVELOX (moxifloxacin) 400mg PB,293824,CDM,636,RC,J1956,HCPCS,Outpatient,,,127.21,76.33,,108.13,85,,86.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.9,32.15,,32.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.81,80.03,,81.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.49,90,,91.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.9,32.15,,32.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.9,32.15,,32.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.94,88,,89.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.12,33.11,,33.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.9,114.49,
CUFF ADULT 1/T BLOOD PRESSURE,493102,CDM,270,RC,,,Outpatient,,,127.25,76.35,,108.16,85,,86.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.91,32.15,,32.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.84,80.03,,81.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.53,90,,91.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.91,32.15,,32.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.91,32.15,,32.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.98,88,,89.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.13,33.11,,33.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.91,114.53,
HEPARIN ANITI-XA  ASSAY  (MAYO),1885520,CDM,300,RC,85520,HCPCS,Outpatient,,,127.25,76.35,,108.16,85,,86.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.84,80.03,,81.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,114.53,90,,91.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.98,88,,89.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.46,114.53,
Testing for presence of drug,1882662,CDM,300,RC,80307,HCPCS,Outpatient,,,127.39,76.43,,108.28,85,,86.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,101.95,80.03,,81.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,114.65,90,,91.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,112.1,88,,89.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.16,114.65,
L/S RATIO  (MAYO),1883663,CDM,300,RC,83661,HCPCS,Outpatient,,,127.5,76.5,,108.38,85,,86.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.04,80.03,,81.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,114.75,90,,91.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,112.2,88,,89.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.64,114.75,
ADENOVIRUS  (MAYO),1886260,CDM,300,RC,86603,HCPCS,Outpatient,,,127.75,76.65,,108.59,85,,86.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.24,80.03,,81.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,114.98,90,,91.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,112.42,88,,89.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.18,114.98,
CORTISOL SALIVA (MAYO),1884879,CDM,300,RC,82533,HCPCS,Outpatient,,,127.83,76.7,,108.66,85,,86.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.3,80.03,,81.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,115.05,90,,92.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,112.49,88,,89.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.12,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.5,115.05,
IMMOBILIZER SHOULDER LARGE VELPEAU,491156,CDM,270,RC,,,Outpatient,,,128,76.8,,108.8,85,,87.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.44,80.03,,81.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,92.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.64,88,,90.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.38,33.11,,33.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.15,115.2,
TUBE INFANT FEEDING 3.5FR 12,493791,CDM,270,RC,,,Outpatient,,,128,76.8,,108.8,85,,87.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.44,80.03,,81.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,92.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.64,88,,90.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.38,33.11,,33.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.15,115.2,
VISIFLOW IRG W/STOMA CONE,497008,CDM,270,RC,,,Outpatient,,,128,76.8,,108.8,85,,87.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.44,80.03,,81.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,92.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.64,88,,90.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.38,33.11,,33.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.15,115.2,
KIT RAPE,497510,CDM,270,RC,,,Outpatient,,,128,76.8,,108.8,85,,87.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.44,80.03,,81.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,92.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.64,88,,90.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.38,33.11,,33.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.15,115.2,
SET DEXTROLYTE II CAPD TRANSFER,498000,CDM,270,RC,,,Outpatient,,,128,76.8,,108.8,85,,87.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.44,80.03,,81.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,92.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.15,32.15,,32.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.64,88,,90.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.38,33.11,,33.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.15,115.2,
"CRYPTOCOCCUS AG, SERUM  (MAYO)",1886641,CDM,300,RC,87899,HCPCS,Outpatient,,,128.25,76.95,,109.01,85,,87.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,102.64,80.03,,82.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,115.43,90,,92.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,112.86,88,,90.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,115.43,
KIT BREASTMILK INITIATION DOUBLE DUET,493113,CDM,270,RC,,,Outpatient,,,128.37,77.02,,109.11,85,,87.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.27,32.15,,33.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.73,80.03,,82.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.53,90,,92.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.27,32.15,,33.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.27,32.15,,33.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.97,88,,90.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.5,33.11,,34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.27,115.53,
DATASCOPE MONITOR CHARGE,6389,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
PULSE OXIMETER SYSTEM,10018,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
KIT RADIAL ARTERY CATHERASATION,49559,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
KIT PERITONEAL LAVAGE,490076,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
SPLINT FRACTOR SMALL RIGHT,491296,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
CANNULA DISPOSABLE 8.4 X 75mm,491540,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
CANNULA DISPOSABLE 6.0 X 75mm,491541,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
SENSOR OXI II I-20 INFANT,496391,CDM,270,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
TEST CARBOXYHEMOGLOBIN,30333,CDM,300,RC,82375,HCPCS,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.62,116.33,
TEST METHEMOGLOBIN,30334,CDM,300,RC,82375,HCPCS,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.62,116.33,
METHEMOGLOBIN,1882376,CDM,300,RC,83050,HCPCS,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.36,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.36,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.21,116.33,
FLUOROSCOPY,1476000,CDM,320,RC,,,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
Mammography of both breasts-2 or more views,22336,CDM,403,RC,77067,HCPCS,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,84.39,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.39,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
EXTUBATION/SUCTION,30315,CDM,410,RC,94002,HCPCS,Outpatient,,,129.25,77.55,,109.86,85,,87.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.44,80.03,,82.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,533.72,102,,,fee schedule,Pays at 102% of CMS APC rate,116.33,90,,93.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,533.72,100,,,fee schedule,Pays at 100% of CMS APC rate,41.55,32.15,,33.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.74,88,,90.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.79,33.11,,34.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.55,116.33,
"P/T UNNA BOOT, EA",39051,CDM,420,RC,29580,HCPCS,Outpatient,,,129.38,77.63,,109.97,85,,87.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.6,32.15,,33.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.54,80.03,,82.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,116.44,90,,93.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.6,32.15,,33.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,41.6,32.15,,33.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.85,88,,91.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.84,33.11,,34.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.6,116.44,
SPECIAL ORDER EXERCISE EQUIPMENT,31141,CDM,270,RC,,,Outpatient,,,129.5,77.7,,110.08,85,,88.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.63,32.15,,33.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.64,80.03,,82.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.55,90,,93.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.63,32.15,,33.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.63,32.15,,33.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.96,88,,91.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.88,33.11,,34.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.63,116.55,
CARBOXYHEMOGLOBIN,1882375,CDM,300,RC,82375,HCPCS,Outpatient,,,129.5,77.7,,110.08,85,,88.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,103.64,80.03,,82.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,116.55,90,,93.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.96,88,,91.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.62,116.55,
LOVENOX (enoxaparin) : 120MG INJ,293474,CDM,250,RC,,,Outpatient,,,130,78,,110.5,85,,88.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.04,80.03,,83.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,90,,93.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.4,88,,91.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.04,33.11,,34.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.8,117,
CARDIZEM (diltiazem) :125MG INJ,293483,CDM,250,RC,,,Outpatient,,,130,78,,110.5,85,,88.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.04,80.03,,83.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,90,,93.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.4,88,,91.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.04,33.11,,34.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.8,117,
MYCOLOG (NYSTATIN/TRIAMCIN) CRM 15GM,297037,CDM,250,RC,,,Outpatient,,,130,78,,110.5,85,,88.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.04,80.03,,83.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,90,,93.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.4,88,,91.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.04,33.11,,34.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.8,117,
AIRWAY 32FR NASOPHARYNGEAL,490028,CDM,270,RC,,,Outpatient,,,130,78,,110.5,85,,88.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.04,80.03,,83.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,90,,93.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.4,88,,91.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.04,33.11,,34.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.8,117,
SPLINT WRIST RIGHT SMALL,491292,CDM,270,RC,,,Outpatient,,,130,78,,110.5,85,,88.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.04,80.03,,83.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,90,,93.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.4,88,,91.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.04,33.11,,34.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.8,117,
ADJUSTABLE SOFT ELBOW SPLINT,314106,CDM,274,RC,L3999,HCPCS,Outpatient,,,130.4,78.24,,110.84,85,,88.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.92,32.15,,33.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.36,80.03,,83.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.36,90,,93.89,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.92,32.15,,33.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.92,32.15,,33.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.75,88,,91.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.18,33.11,,34.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.92,117.36,
SUPPORTER SMALL ATHLETIC ADULT 26-32,493356,CDM,270,RC,,,Outpatient,,,130.5,78.3,,110.93,85,,88.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.44,80.03,,83.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.45,90,,93.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.84,88,,91.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.21,33.11,,34.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.96,117.45,
"ALDOSTERONE, SERUM  (MAYO)",1882088,CDM,300,RC,82088,HCPCS,Outpatient,,,130.5,78.3,,110.93,85,,88.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.44,80.03,,83.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,41.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,117.45,90,,93.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.84,88,,91.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.25,117.45,
GLU PHOS ISOMERASE ERYTHRO  (MAYO),1882964,CDM,300,RC,84087,HCPCS,Outpatient,,,130.5,78.3,,110.93,85,,88.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.44,80.03,,83.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.94,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,117.45,90,,93.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.94,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.84,88,,91.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,117.45,
MM MAMMO DIAG BILAT,22136,CDM,401,RC,77056,HCPCS,Outpatient,,,130.5,78.3,,110.93,85,,88.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.44,80.03,,83.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.45,90,,93.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.84,88,,91.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.21,33.11,,34.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.96,117.45,
Radiologic examination of the lower leg,22074,CDM,320,RC,73590,HCPCS,Outpatient,,,130.79,78.47,,111.17,85,,88.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.05,32.15,,33.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.67,80.03,,83.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,117.71,90,,94.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.05,32.15,,33.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.05,32.15,,33.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.1,88,,92.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.3,33.11,,34.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.05,117.71,
STADOL NASAL SPRAY,297913,CDM,250,RC,S0012,HCPCS,Outpatient,,,130.81,78.49,,111.19,85,,88.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.06,32.15,,33.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.69,80.03,,83.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.73,90,,94.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.06,32.15,,33.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.06,32.15,,33.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.11,88,,92.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.31,33.11,,34.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.06,117.73,
COLLAR CERVICAL LARGE,491184,CDM,274,RC,L0120,HCPCS,Outpatient,,,131,78.6,,111.35,85,,89.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.84,80.03,,83.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.9,90,,94.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.28,88,,92.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.37,33.11,,34.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.12,117.9,
COLLAR CERVICAL X-LARGE,491185,CDM,274,RC,L0120,HCPCS,Outpatient,,,131,78.6,,111.35,85,,89.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.84,80.03,,83.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.9,90,,94.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.28,88,,92.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.37,33.11,,34.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.12,117.9,
COLLAR CERVICAL SMALL,491196,CDM,274,RC,L0120,HCPCS,Outpatient,,,131,78.6,,111.35,85,,89.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.84,80.03,,83.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.9,90,,94.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.12,32.15,,33.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.28,88,,92.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.37,33.11,,34.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.12,117.9,
FACTOR XI  (MAYO),1885270,CDM,300,RC,85270,HCPCS,Outpatient,,,131,78.6,,111.35,85,,89.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.84,80.03,,83.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,117.9,90,,94.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.28,88,,92.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.52,117.9,
KLEIHAUER ACID ELUTION,1885461,CDM,300,RC,85460,HCPCS,Outpatient,,,131,78.6,,111.35,85,,89.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.84,80.03,,83.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.88,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,117.9,90,,94.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.88,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,3.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.28,88,,92.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.04,117.9,
"Radiologic examination, elbow; 3 or more views",22275,CDM,320,RC,73080,HCPCS,Outpatient,,,131.25,78.75,,111.56,85,,89.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.2,32.15,,33.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.04,80.03,,84.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,118.13,90,,94.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.2,32.15,,33.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.2,32.15,,33.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.5,88,,92.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.46,33.11,,34.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.2,118.13,
COAGULATION CONSULT PROLONG CLOT MAYO,1885306,CDM,300,RC,85732,HCPCS,Outpatient,,,131.5,78.9,,111.78,85,,89.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.24,80.03,,84.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,118.35,90,,94.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.72,88,,92.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.14,118.35,
Single view,22025,CDM,320,RC,71045,HCPCS,Outpatient,,,131.61,78.97,,111.87,85,,89.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.33,80.03,,84.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,118.45,90,,94.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.82,88,,92.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.58,33.11,,34.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.31,118.45,
"Radiologic examination of the neck/spine, 2-3 views",22033,CDM,320,RC,72040,HCPCS,Outpatient,,,131.61,78.97,,111.87,85,,89.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.33,80.03,,84.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,118.45,90,,94.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.82,88,,92.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.58,33.11,,34.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.31,118.45,
Radiologic examination of the knee with 3 views,22154,CDM,320,RC,73562,HCPCS,Outpatient,,,131.61,78.97,,111.87,85,,89.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.33,80.03,,84.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,118.45,90,,94.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.82,88,,92.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.58,33.11,,34.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.31,118.45,
Radiologic examination of the foot with 3 or more views,22280,CDM,320,RC,73630,HCPCS,Outpatient,,,131.61,78.97,,111.87,85,,89.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.33,80.03,,84.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,118.45,90,,94.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.82,88,,92.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.58,33.11,,34.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.31,118.45,
Radiologic examination of the lower leg,22363,CDM,320,RC,73590,HCPCS,Outpatient,,,131.61,78.97,,111.87,85,,89.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.33,80.03,,84.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,118.45,90,,94.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.82,88,,92.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.58,33.11,,34.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.31,118.45,
Up to 3 views,22366,CDM,320,RC,73110,HCPCS,Outpatient,,,131.61,78.97,,111.87,85,,89.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.33,80.03,,84.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,118.45,90,,94.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.31,32.15,,33.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.82,88,,92.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.58,33.11,,34.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.31,118.45,
TRUSOPT 2% (DORZOLAMIDE) OPHTH SOL 10 ML,291103,CDM,250,RC,,,Outpatient,,,131.75,79.05,,111.99,85,,89.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.36,32.15,,33.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.44,80.03,,84.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.58,90,,94.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.36,32.15,,33.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.36,32.15,,33.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.94,88,,92.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.62,33.11,,34.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.36,118.58,
DO NOT USE,322025,CDM,440,RC,92510,HCPCS,Outpatient,,,131.75,79.05,,111.99,85,,89.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.36,32.15,,33.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.44,80.03,,84.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.58,90,,94.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.36,32.15,,33.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.36,32.15,,33.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.94,88,,92.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.62,33.11,,34.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.36,118.58,
MAXIPIME (cefepime)  2GM/100 ML NSPB,293879,CDM,636,RC,J0692,HCPCS,Outpatient,,,131.86,79.12,,112.08,85,,89.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.39,32.15,,33.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.53,80.03,,84.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.67,90,,94.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.39,32.15,,33.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.39,32.15,,33.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,88,,92.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.66,33.11,,34.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.39,118.67,
ALPHAGAN 0.2% (BRIMONIDINE ) OPHTH 5ML,291150,CDM,250,RC,,,Outpatient,,,132,79.2,,112.2,85,,89.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.44,32.15,,33.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.64,80.03,,84.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.8,90,,95.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.44,32.15,,33.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.44,32.15,,33.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.16,88,,92.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.71,33.11,,34.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.44,118.8,
ALPHAGAN 0.15% (BRIMONIDINE) OPHTH 5ML,297771,CDM,250,RC,,,Outpatient,,,132,79.2,,112.2,85,,89.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.44,32.15,,33.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,105.64,80.03,,84.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.8,90,,95.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.44,32.15,,33.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.44,32.15,,33.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.16,88,,92.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.71,33.11,,34.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.44,118.8,
"NICOTINE & METABOLITES, URINE (MAYO)",1884851,CDM,300,RC,80323,HCPCS,Outpatient,,,132.26,79.36,,112.42,85,,89.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,105.85,80.03,,84.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.03,90,,95.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,37.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,116.39,88,,93.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.75,119.03,
SPIRIVA (tiopropium) W/HANDIHALER #5,292130,CDM,250,RC,,,Outpatient,,,132.5,79.5,,112.63,85,,90.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.6,32.15,,34.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.04,80.03,,84.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.25,90,,95.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.6,32.15,,34.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.6,32.15,,34.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.6,88,,93.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.87,33.11,,35.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.6,119.25,
"INTRINSIC FACTOR BLOCKING AB, S  (MAYO)",1886345,CDM,300,RC,86340,HCPCS,Outpatient,,,132.5,79.5,,112.63,85,,90.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.04,80.03,,84.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,119.25,90,,95.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,116.6,88,,93.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,119.25,
Occupational therapy,593009,CDM,430,RC,97535,HCPCS,Outpatient,,,132.55,79.53,,112.67,85,,90.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.08,80.03,,84.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,119.3,90,,95.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.64,88,,93.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.89,33.11,,35.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.61,119.3,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",593012,CDM,430,RC,97110,HCPCS,Outpatient,,,132.55,79.53,,112.67,85,,90.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.08,80.03,,84.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.69,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,119.3,90,,95.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,28.69,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.64,88,,93.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.89,33.11,,35.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.61,119.3,
A technique used by physical therapists to restore normal body movement patterns,593025,CDM,430,RC,97112,HCPCS,Outpatient,,,132.55,79.53,,112.67,85,,90.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.08,80.03,,84.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,119.3,90,,95.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,42.61,32.15,,34.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.64,88,,93.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.89,33.11,,35.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.61,119.3,
MTHFR MUTATION B PANEL  (MAYO),1883903,CDM,300,RC,83896,HCPCS,Outpatient,,,132.75,79.65,,112.84,85,,90.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.68,32.15,,34.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.24,80.03,,84.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.48,90,,95.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.68,32.15,,34.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.68,32.15,,34.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.82,88,,93.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.95,33.11,,35.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.68,119.48,
PROTEIN C-FUNC ACTIVITY  (MAYO),1886998,CDM,300,RC,85303,HCPCS,Outpatient,,,132.75,79.65,,112.84,85,,90.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.24,80.03,,84.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.11,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,119.48,90,,95.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.11,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,116.82,88,,93.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.39,119.48,
CARDIZEM (diltiazem) :100MG INJ,293570,CDM,250,RC,,,Outpatient,,,133,79.8,,113.05,85,,90.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.44,80.03,,85.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.7,90,,95.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.04,88,,93.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.04,33.11,,35.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.76,119.7,
MYCOSTATIN (nystatin ) VAG TAB BOX(15),296037,CDM,250,RC,,,Outpatient,,,133,79.8,,113.05,85,,90.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.44,80.03,,85.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.7,90,,95.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.04,88,,93.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.04,33.11,,35.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.76,119.7,
ACULAR (ketorolac) 0.4% 5ML MDV,297775,CDM,250,RC,,,Outpatient,,,133,79.8,,113.05,85,,90.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.44,80.03,,85.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.7,90,,95.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.04,88,,93.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.04,33.11,,35.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.76,119.7,
"FUNGI ID, MALDI-TOF  (MAYO)",1887107,CDM,300,RC,87107,HCPCS,Outpatient,,,133,79.8,,113.05,85,,90.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.44,80.03,,85.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,119.7,90,,95.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.04,88,,93.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,119.7,
REGITINE (phentolamine) 5MG INJ,293154,CDM,636,RC,J2760,HCPCS,Outpatient,,,133,79.8,,113.05,85,,90.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.44,80.03,,85.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,462.73,102,,,fee schedule,Pays at 102% of CMS APC rate,119.7,90,,95.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.73,100,,,fee schedule,Pays at 100% of CMS APC rate,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.04,88,,93.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.04,33.11,,35.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.76,119.7,
VIBATIV (telavancin) 250MG VIAL,296427,CDM,636,RC,J3095,HCPCS,Outpatient,,,133,79.8,,113.05,85,,90.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.44,80.03,,85.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.29,102,,,fee schedule,Pays at 102% of CMS APC rate,119.7,90,,95.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7.29,100,,,fee schedule,Pays at 100% of CMS APC rate,42.76,32.15,,34.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.04,88,,93.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.04,33.11,,35.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.76,119.7,
MYCOPLASMA PNEUMONIAE IGA  (MAYO),1886263,CDM,300,RC,86738,HCPCS,Outpatient,,,133.25,79.95,,113.26,85,,90.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,106.64,80.03,,85.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,119.93,90,,95.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.26,88,,93.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.66,119.93,
TOBRADEX  (tobra/dexameth) OPTH 2.5ML,297762,CDM,250,RC,,,Outpatient,,,133.33,80,,113.33,85,,90.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.87,32.15,,34.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.7,80.03,,85.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120,90,,96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.87,32.15,,34.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.87,32.15,,34.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.33,88,,93.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.15,33.11,,35.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.87,120,
DMSO (dimethyl sulfoxide) 54GM 50ML,293528,CDM,250,RC,,,Outpatient,,,133.34,80,,113.34,85,,90.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.87,32.15,,34.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.71,80.03,,85.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.01,90,,96.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.87,32.15,,34.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.87,32.15,,34.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.34,88,,93.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.15,33.11,,35.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.87,120.01,
ALINIA (nitazoxanide)100MG/5ML    60ML,298048,CDM,250,RC,,,Outpatient,,,133.5,80.1,,113.48,85,,90.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.92,32.15,,34.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.84,80.03,,85.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.15,90,,96.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.92,32.15,,34.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.92,32.15,,34.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.48,88,,93.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.2,33.11,,35.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.92,120.15,
P/T WRIST EXTENSION COCK-UP SPLINT,313906,CDM,274,RC,L3906,HCPCS,Outpatient,,,133.5,80.1,,113.48,85,,90.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.92,32.15,,34.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.84,80.03,,85.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.15,90,,96.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.92,32.15,,34.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,42.92,32.15,,34.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.48,88,,93.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.2,33.11,,35.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.92,120.15,
Up to 3 views,22267,CDM,320,RC,73110,HCPCS,Outpatient,,,133.95,80.37,,113.86,85,,91.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.06,32.15,,34.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.2,80.03,,85.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,120.56,90,,96.45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.06,32.15,,34.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,43.06,32.15,,34.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.88,88,,94.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.35,33.11,,35.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.06,120.56,
Test to predict likelihood of gestational diabetes,1882952,CDM,300,RC,82951,HCPCS,Outpatient,,,134,80.4,,113.9,85,,91.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.24,80.03,,85.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,120.6,90,,96.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.92,88,,94.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,120.6,
Blood test to determine infection with Hepatitis C,1886295,CDM,300,RC,86803,HCPCS,Outpatient,,,134.25,80.55,,114.11,85,,91.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.44,80.03,,85.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.55,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,120.83,90,,96.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.55,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,118.14,88,,94.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10,120.83,
ASTELIN (AZELASTINE)NASAL SPRAY 30ML,297908,CDM,250,RC,,,Outpatient,,,134.3,80.58,,114.16,85,,91.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.18,32.15,,34.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.48,80.03,,85.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.87,90,,96.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.18,32.15,,34.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.18,32.15,,34.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.18,88,,94.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.47,33.11,,35.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.18,120.87,
VAC 500 ml ATS CANISTER,4382,CDM,270,RC,,,Outpatient,,,134.5,80.7,,114.33,85,,91.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.64,80.03,,86.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.05,90,,96.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.36,88,,94.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.53,33.11,,35.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.24,121.05,
CATH THORACIC 36FR RIGHT ANGLE 20,49596,CDM,270,RC,,,Outpatient,,,134.5,80.7,,114.33,85,,91.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.64,80.03,,86.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.05,90,,96.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.36,88,,94.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.53,33.11,,35.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.24,121.05,
CATH THORACIC 24FR RIGHT ANGLE,49599,CDM,270,RC,,,Outpatient,,,134.5,80.7,,114.33,85,,91.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.64,80.03,,86.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.05,90,,96.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.36,88,,94.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.53,33.11,,35.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.24,121.05,
"FENTANYL, URINE   (MAYO)",1880101,CDM,300,RC,80302,HCPCS,Outpatient,,,134.5,80.7,,114.33,85,,91.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.64,80.03,,86.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.05,90,,96.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.36,88,,94.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.53,33.11,,35.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.24,121.05,
MOLD SENSITIVITY  (MAYO),1881230,CDM,300,RC,87188,HCPCS,Outpatient,,,134.5,80.7,,114.33,85,,91.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.64,80.03,,86.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.05,90,,96.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,118.36,88,,94.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.34,121.05,
A test used to determine which medications work on bacteria for fungi,1887187,CDM,300,RC,87186,HCPCS,Outpatient,,,134.5,80.7,,114.33,85,,91.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.64,80.03,,86.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.05,90,,96.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,118.36,88,,94.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.87,121.05,
"HIV-1 DNA, QUANT, PLASMA (MAYO)",1884890,CDM,300,RC,87536,HCPCS,Outpatient,,,134.86,80.92,,114.63,85,,91.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.93,80.03,,86.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,86.8,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.37,90,,97.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.8,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,118.68,88,,94.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,56.5,121.37,
OPEN BED WARMER,30080,CDM,270,RC,,,Outpatient,,,135,81,,114.75,85,,91.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.04,80.03,,86.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.5,90,,97.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135,,,,Other,Not Separately reimbursable,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.8,88,,95.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.7,33.11,,35.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.4,121.5,
SETUP SEQUENTIAL COMP. DEVICE,31101,CDM,270,RC,,,Outpatient,,,135,81,,114.75,85,,91.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.04,80.03,,86.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.5,90,,97.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135,,,,Other,Not Separately reimbursable,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.8,88,,95.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.7,33.11,,35.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.4,121.5,
P/T ADJUSTABLE SACROILIAC BRACE,310,CDM,274,RC,L0621,HCPCS,Outpatient,,,135,81,,114.75,85,,91.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.04,80.03,,86.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,89.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.5,90,,97.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.8,88,,95.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.7,33.11,,35.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.4,121.5,
SINUSES <3V,22011,CDM,320,RC,70210,HCPCS,Outpatient,,,135,81,,114.75,85,,91.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.04,80.03,,86.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,121.5,90,,97.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,43.4,32.15,,34.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.8,88,,95.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.7,33.11,,35.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.4,121.5,
SYSTEM NURSING SUPPLEMENTAL,499614,CDM,270,RC,,,Outpatient,,,135.25,81.15,,114.96,85,,91.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.48,32.15,,34.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.24,80.03,,86.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.73,90,,97.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.48,32.15,,34.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.25,,,,Other,Not Separately reimbursable,43.48,32.15,,34.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.02,88,,95.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.78,33.11,,35.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.48,121.73,
BARBITURATES CONFIRMATION  (MAYO),1882647,CDM,300,RC,80345,HCPCS,Outpatient,,,135.25,81.15,,114.96,85,,91.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.24,80.03,,86.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.73,90,,97.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,14.41,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.02,88,,95.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.84,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.41,121.73,
"....FOLATE, RBC  (MAYO)",1882745,CDM,300,RC,82747,HCPCS,Outpatient,,,135.25,81.15,,114.96,85,,91.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.24,80.03,,86.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.73,90,,97.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.02,88,,95.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.78,121.73,
FACTOR XII  (MAYO),1885276,CDM,300,RC,85280,HCPCS,Outpatient,,,135.25,81.15,,114.96,85,,91.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.24,80.03,,86.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.73,90,,97.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.02,88,,95.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.34,121.73,
"DRESSING, VAC GRANFOAM SMALL",43835,CDM,270,RC,,,Outpatient,,,135.5,81.3,,115.18,85,,92.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.44,80.03,,86.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.95,90,,97.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.24,88,,95.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.86,33.11,,35.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.56,121.95,
Blood test to determine existence of certain bacterium that causes syphilis,1884911,CDM,300,RC,86780,HCPCS,Outpatient,,,135.5,81.3,,115.18,85,,92.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.44,80.03,,86.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.95,90,,97.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.24,88,,95.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.86,33.11,,35.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.56,121.95,
RMSF IGG  (MAYO),1886721,CDM,300,RC,86757,HCPCS,Outpatient,,,135.5,81.3,,115.18,85,,92.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,108.44,80.03,,86.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.95,90,,97.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.24,88,,95.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,121.95,
Blood test to determine existence of certain bacterium that causes syphilis,1886781,CDM,300,RC,86780,HCPCS,Outpatient,,,135.5,81.3,,115.18,85,,92.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.44,80.03,,86.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,121.95,90,,97.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,43.56,32.15,,34.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.24,88,,95.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.86,33.11,,35.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.56,121.95,
BRACE KNEE 19  UNIVERSAL,491179,CDM,270,RC,,,Outpatient,,,135.51,81.31,,115.18,85,,92.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.57,32.15,,34.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.45,80.03,,86.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.96,90,,97.57,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.57,32.15,,34.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.57,32.15,,34.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.25,88,,95.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.87,33.11,,35.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.57,121.96,
DRESSING ARGLAES POWDER 5GM BOTTLE,498026,CDM,272,RC,,,Outpatient,,,135.75,81.45,,115.39,85,,92.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.64,32.15,,34.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.64,80.03,,86.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.18,90,,97.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.64,32.15,,34.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.64,32.15,,34.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.46,88,,95.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.95,33.11,,35.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.64,122.18,
OMNICEF (cefdinir) 250MG/5ML SUSP 60ML,295194,CDM,250,RC,,,Outpatient,,,136,81.6,,115.6,85,,92.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.84,80.03,,87.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,90,,97.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.68,88,,95.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.03,33.11,,36.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.72,122.4,
DRESSING DUODERM SIGNAL 6 X 7,493264,CDM,270,RC,,,Outpatient,,,136,81.6,,115.6,85,,92.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.84,80.03,,87.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,90,,97.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.68,88,,95.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.03,33.11,,36.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.72,122.4,
AIRWAY 28FR NASOPHARYNGEAL,490026,CDM,270,RC,,,Outpatient,,,136.25,81.75,,115.81,85,,92.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.8,32.15,,35.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.04,80.03,,87.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.63,90,,98.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.8,32.15,,35.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.8,32.15,,35.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.9,88,,95.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.11,33.11,,36.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.8,122.63,
OMNICEF (CEFDINIR) 125MG/5ML SUSP 100ML,295193,CDM,250,RC,,,Outpatient,,,136.35,81.81,,115.9,85,,92.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.84,32.15,,35.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,80.03,,87.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.72,90,,98.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.84,32.15,,35.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.84,32.15,,35.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.99,88,,95.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.15,33.11,,36.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.84,122.72,
OFIRMEV (acetaminophen) 1000MG/100ML INJ,293574,CDM,636,RC,J0131,HCPCS,Outpatient,,,136.4,81.84,,115.94,85,,92.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.85,32.15,,35.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.16,80.03,,87.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.76,90,,98.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.85,32.15,,35.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.85,32.15,,35.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.03,88,,96.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.16,33.11,,36.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.85,122.76,
CDS DELIVERY KIT,491837,CDM,270,RC,,,Outpatient,,,136.5,81.9,,116.03,85,,92.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.24,80.03,,87.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.85,90,,98.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.12,88,,96.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.2,33.11,,36.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.88,122.85,
CMV PCR PLASMA  (MAYO),1887493,CDM,300,RC,87497,HCPCS,Outpatient,,,136.5,81.9,,116.03,85,,92.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.24,80.03,,87.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,43.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,122.85,90,,98.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.12,88,,96.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,53.87,122.85,
P/T PROSTHETIC SUBSEQUENT TRAINING,31127,CDM,420,RC,97763,HCPCS,Outpatient,,,136.5,81.9,,116.03,85,,92.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.24,80.03,,87.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,50.43,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,122.85,90,,98.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.43,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.12,88,,96.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.2,33.11,,36.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.88,122.85,
RT TIME 1/2 HOUR,30360,CDM,270,RC,,,Outpatient,,,137.5,82.5,,116.88,85,,93.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.04,80.03,,88.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.75,90,,99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121,88,,96.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.53,33.11,,36.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.21,123.75,
O/T WRIST EXTENSION COCK-UP SPLINT,3936,CDM,274,RC,L3906,HCPCS,Outpatient,,,137.75,82.65,,117.09,85,,93.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.29,32.15,,35.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.24,80.03,,88.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.98,90,,99.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.29,32.15,,35.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.29,32.15,,35.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.22,88,,96.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.61,33.11,,36.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.29,123.98,
"STRIATIONAL, STRIATED MUSCLE AB  (MAYO)",1883501,CDM,300,RC,83520,HCPCS,Outpatient,,,137.75,82.65,,117.09,85,,93.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,110.24,80.03,,88.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,123.98,90,,99.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,121.22,88,,96.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,123.98,
INHIBIN A  (MAYO),1883524,CDM,300,RC,83520,HCPCS,Outpatient,,,137.75,82.65,,117.09,85,,93.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,110.24,80.03,,88.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,123.98,90,,99.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,121.22,88,,96.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,123.98,
ALPHAGAN 0.15% (BRIMONIDINE) OPHTH:U/D,303960,CDM,250,RC,,,Outpatient,,,137.99,82.79,,117.29,85,,93.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.36,32.15,,35.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.43,80.03,,88.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.19,90,,99.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.36,32.15,,35.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.36,32.15,,35.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.43,88,,97.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.69,33.11,,36.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.36,124.19,
TRYPSIN  (MAYO),1884485,CDM,300,RC,84485,HCPCS,Outpatient,,,138,82.8,,117.3,85,,93.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,110.44,80.03,,88.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,124.2,90,,99.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,9.44,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,121.44,88,,97.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.44,124.2,
QVAR (beclomethasone) HFA 40 MCG INHALER,291039,CDM,250,RC,,,Outpatient,,,138.1,82.86,,117.39,85,,93.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.4,32.15,,35.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.52,80.03,,88.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.29,90,,99.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.4,32.15,,35.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.4,32.15,,35.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.53,88,,97.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.72,33.11,,36.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.4,124.29,
P/T EVAL FOR OT MODALITY,333101,CDM,424,RC,97001,HCPCS,Outpatient,,,138.4,83.04,,117.64,85,,94.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.5,32.15,,35.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.76,80.03,,88.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.56,90,,99.65,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.5,32.15,,35.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.5,32.15,,35.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.79,88,,97.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.82,33.11,,36.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.5,124.56,
P/T TNS INSTRUCTION,336,CDM,420,RC,64550,HCPCS,Outpatient,,,138.5,83.1,,117.73,85,,94.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.84,80.03,,88.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.65,90,,99.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.88,88,,97.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.86,33.11,,36.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.53,124.65,
MMT-TOTAL BODY INCLUDING HANDS,319,CDM,430,RC,95833,HCPCS,Outpatient,,,138.5,83.1,,117.73,85,,94.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.84,80.03,,88.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.65,90,,99.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.88,88,,97.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.86,33.11,,36.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.53,124.65,
O/T TNS INSTRUCTION,3361,CDM,430,RC,64550,HCPCS,Outpatient,,,138.5,83.1,,117.73,85,,94.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.84,80.03,,88.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.65,90,,99.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.88,88,,97.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.86,33.11,,36.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.53,124.65,
S/T FEEDING/SWALLOWING EVAL 30-Min,322002,CDM,440,RC,92610,HCPCS,Outpatient,,,138.5,83.1,,117.73,85,,94.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.84,80.03,,88.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,68.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,124.65,90,,99.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.88,88,,97.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.86,33.11,,36.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.53,124.65,
Therapy for speech or hearing,322011,CDM,440,RC,92507,HCPCS,Outpatient,,,138.5,83.1,,117.73,85,,94.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.84,80.03,,88.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,124.65,90,,99.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.88,88,,97.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.86,33.11,,36.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.53,124.65,
S/T TX SPEECH GENERATING DEVICE,322016,CDM,440,RC,92609,HCPCS,Outpatient,,,138.5,83.1,,117.73,85,,94.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.84,80.03,,88.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,100.14,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,124.65,90,,99.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.14,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.88,88,,97.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.86,33.11,,36.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.53,124.65,
PAD LIFEPAK 8 DEFIB,491911,CDM,450,RC,,,Outpatient,,,138.5,83.1,,117.73,85,,94.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.84,80.03,,88.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.65,90,,99.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.53,32.15,,35.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.88,88,,97.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.86,33.11,,36.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.53,124.65,
*CONCHA WATER/COLUMN,30270,CDM,270,RC,,,Outpatient,,,138.75,83.25,,117.94,85,,94.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.61,32.15,,35.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.04,80.03,,88.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.88,90,,99.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.61,32.15,,35.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.61,32.15,,35.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.1,88,,97.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.94,33.11,,36.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.61,124.88,
"EXTRAGENITAL CYTOLOGY( FLUIDS,BRUSHINGS)",2188109,CDM,310,RC,88104,HCPCS,Outpatient,,,138.75,83.25,,117.94,85,,94.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.04,80.03,,88.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,124.88,90,,99.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.1,88,,97.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,42.68,124.88,
NON-GYN INTERPRETATION ONLY,2188160,CDM,310,RC,88160,HCPCS,Outpatient,,,138.75,83.25,,117.94,85,,94.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.04,80.03,,88.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,124.88,90,,99.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.1,88,,97.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,46.13,124.88,
FLUORESCITE 10% (sod fluorescein) INJ,293142,CDM,250,RC,,,Outpatient,,,138.87,83.32,,118.04,85,,94.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.65,32.15,,35.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.14,80.03,,88.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.98,90,,99.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.65,32.15,,35.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.65,32.15,,35.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.21,88,,97.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.98,33.11,,36.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.65,124.98,
EPOGEN *NON DIALYSIS* 3000UNIT INJ,293484,CDM,636,RC,J0885,HCPCS,Outpatient,,,139,83.4,,118.15,85,,94.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.24,80.03,,88.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.23,102,,,fee schedule,Pays at 102% of CMS APC rate,125.1,90,,100.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.23,100,,,fee schedule,Pays at 100% of CMS APC rate,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.32,88,,97.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.09,125.1,
HAND SPLINT FIT/CONSTRUCTION III,389,CDM,430,RC,97504,HCPCS,Outpatient,,,139.2,83.52,,118.32,85,,94.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.75,32.15,,35.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.4,80.03,,89.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.28,90,,100.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.75,32.15,,35.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.75,32.15,,35.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.5,88,,98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.09,33.11,,36.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.75,125.28,
Occupational therapy,593041,CDM,430,RC,97535,HCPCS,Outpatient,,,139.2,83.52,,118.32,85,,94.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.75,32.15,,35.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.4,80.03,,89.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,125.28,90,,100.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.75,32.15,,35.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,44.75,32.15,,35.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.5,88,,98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.09,33.11,,36.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.75,125.28,
AQUAMEPHYTON (vitamin K) 10MG/ML AMP,293014,CDM,636,RC,J3430,HCPCS,Outpatient,,,139.63,83.78,,118.69,85,,94.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.75,80.03,,89.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.67,90,,100.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.87,88,,98.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.98,125.67,
MRSA SCREEN (PCR),1887062,CDM,300,RC,87641,HCPCS,Outpatient,,,139.69,83.81,,118.74,85,,94.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.79,80.03,,89.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,125.72,90,,100.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.93,88,,98.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,125.72,
MRSA SCREEN (PCR) - OPS,1887063,CDM,300,RC,87641,HCPCS,Outpatient,,,139.69,83.81,,118.74,85,,94.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.79,80.03,,89.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,125.72,90,,100.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.93,88,,98.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,125.72,
Test that detects Chlamydia,1887490,CDM,300,RC,87491,HCPCS,Outpatient,,,139.69,83.81,,118.74,85,,94.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.79,80.03,,89.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,125.72,90,,100.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.93,88,,98.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,125.72,
Blood test for an STD,1887591,CDM,300,RC,87591,HCPCS,Outpatient,,,139.69,83.81,,118.74,85,,94.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.79,80.03,,89.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,125.72,90,,100.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.93,88,,98.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.42,125.72,
ALPHA I ANTITRYPSIN  (MAYO),1886067,CDM,300,RC,82103,HCPCS,Outpatient,,,139.73,83.84,,118.77,85,,95.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.83,80.03,,89.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.7,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,125.76,90,,100.61,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.7,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.96,88,,98.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.4,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.89,125.76,
Ultrasound of bladder to measure urine capacity,1451798,CDM,450,RC,51798,HCPCS,Outpatient,,,139.75,83.85,,118.79,85,,95.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.93,32.15,,35.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.84,80.03,,89.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,125.78,90,,100.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.93,32.15,,35.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,44.93,32.15,,35.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.98,88,,98.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.27,33.11,,37.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.93,125.78,
SARS-CoV-2 IGG AB SERUM  (MAYO),1884886,CDM,300,RC,86769,HCPCS,Outpatient,,,139.78,83.87,,118.81,85,,95.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.87,80.03,,89.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,42.97,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,125.8,90,,100.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,42.97,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,123.01,88,,98.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.31,125.8,
CLINICAL CHEMISTRY TEST  (MAYO),1884809,CDM,300,RC,84999,HCPCS,Outpatient,,,140,84,,119,85,,95.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.04,80.03,,89.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,90,,100.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.2,88,,98.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.35,33.11,,37.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.01,126,
SET PAD,6593668,CDM,480,RC,93668,HCPCS,Outpatient,,,140,84,,119,85,,95.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.04,80.03,,89.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.09,102,,,fee schedule,Pays at 102% of CMS APC rate,126,90,,100.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.09,100,,,fee schedule,Pays at 100% of CMS APC rate,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.2,88,,98.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.35,33.11,,37.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.01,126,
CIPRO (ciprofloxacin) 400MG /D5 200ML PB,293399,CDM,636,RC,J0744,HCPCS,Outpatient,,,140,84,,119,85,,95.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.04,80.03,,89.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,90,,100.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.01,32.15,,36.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.2,88,,98.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.35,33.11,,37.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.01,126,
FORCEP ALLIGATOR 5 1/2  DISPOSABLE,4910087,CDM,270,RC,,,Outpatient,,,140.25,84.15,,119.21,85,,95.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.09,32.15,,36.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.24,80.03,,89.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.23,90,,100.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.09,32.15,,36.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.09,32.15,,36.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.42,88,,98.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.44,33.11,,37.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.09,126.23,
ALBUMIN 5%: 12.5GM/250ML,293360,CDM,250,RC,,,Outpatient,,,141.37,84.82,,120.16,85,,96.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.45,32.15,,36.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.14,80.03,,90.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.23,90,,101.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.45,32.15,,36.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.45,32.15,,36.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.41,88,,99.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.81,33.11,,37.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.45,127.23,
SPINE THORACOLUMBAR AP/LAT 2 VIEWS,22037,CDM,320,RC,72080,HCPCS,Outpatient,,,141.45,84.87,,120.23,85,,96.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.48,32.15,,36.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.2,80.03,,90.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,127.31,90,,101.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.48,32.15,,36.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,45.48,32.15,,36.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.48,88,,99.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.83,33.11,,37.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.48,127.31,
"ID MALDI-TOF MS, YEAST  (MAYO)",1887105,CDM,300,RC,87106,HCPCS,Outpatient,,,141.6,84.96,,120.36,85,,96.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.32,80.03,,90.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.44,90,,101.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.61,88,,99.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.98,127.44,
PURKINJE CELL CYTOPLAS AB TYPE 1 (MAYO),1884688,CDM,300,RC,86255,HCPCS,Outpatient,,,141.63,84.98,,120.39,85,,96.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.35,80.03,,90.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.47,90,,101.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.63,88,,99.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.47,
ANTI-NEURONAL NUCLEAR AB TYPE 3 (MAYO),1884692,CDM,300,RC,86255,HCPCS,Outpatient,,,141.63,84.98,,120.39,85,,96.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.35,80.03,,90.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.47,90,,101.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.63,88,,99.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.47,
PURKINJE CELL CYTOPLAS AB TYPE 1 (MAYO),1884855,CDM,300,RC,86255,HCPCS,Outpatient,,,141.63,84.98,,120.39,85,,96.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.35,80.03,,90.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.47,90,,101.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.63,88,,99.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.47,
ANTI-NEURONAL NUCLEAR AB TYPE 3 (MAYO),1884859,CDM,300,RC,86255,HCPCS,Outpatient,,,141.63,84.98,,120.39,85,,96.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.35,80.03,,90.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.47,90,,101.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.63,88,,99.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.47,
ANTI-NEURONAL NUCLEAR AB TYPE 1 (MAYO),1884301,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
PURKINJE CELL CYTOPLAS AB TYPE TR (MAYO),1884687,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
PURKINJE CELL CYTOPLAS AB TYPE 2 (MAYO),1884689,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
CRMP-5-IGG (MAYO),1884690,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
ANTI-NEURONAL NUCLEAR AB TYPE 2 (MAYO),1884691,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
AMPHYIPHYSIN AB (MAYO),1884693,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
ANTI-GLIAL NUCLEAR AB TYPE 1 (MAYO),1884694,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
ANTI-NEURONAL NUCLEAR AB TYPE 2 (MAYO),1884853,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
ANTI-NEURONAL NUCLEAR AB TYPE 1 (MAYO),1884854,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
AMPHYIPHYSIN AB CSF (MAYO),1884856,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
PURKINJE CELL CYTOPLAS AB TYPE TR (MAYO),1884857,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
PURKINJE CELL CYTOPLAS AB TYPE 2 (MAYO),1884858,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
CRMP-5-IGG CSF (MAYO),1884860,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
ANTI-GLIAL NUCLEAR AB TYPE 1 (MAYO),1884861,CDM,300,RC,86255,HCPCS,Outpatient,,,141.65,84.99,,120.4,85,,96.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,113.36,80.03,,90.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,127.49,90,,101.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.65,88,,99.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,127.49,
BLANKET HYPOTHERMIA 25 X 64,490012,CDM,270,RC,,,Outpatient,,,142,85.2,,120.7,85,,96.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.65,32.15,,36.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.64,80.03,,90.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.8,90,,102.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.65,32.15,,36.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.65,32.15,,36.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.96,88,,99.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.02,33.11,,37.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.65,127.8,
CAM WALKER; LARGE,314046,CDM,270,RC,L2112,HCPCS,Outpatient,,,142.25,85.35,,120.91,85,,96.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.73,32.15,,36.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.84,80.03,,91.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.03,90,,102.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.73,32.15,,36.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.73,32.15,,36.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,125.18,88,,100.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.1,33.11,,37.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.73,128.03,
"...BORDETELLA PERTUS(IGG,IGA & IGM) MAYO",1886615,CDM,300,RC,,,Outpatient,,,142.25,85.35,,120.91,85,,96.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.73,32.15,,36.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.84,80.03,,91.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.03,90,,102.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.73,32.15,,36.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.73,32.15,,36.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,125.18,88,,100.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.1,33.11,,37.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.73,128.03,
AMANTADINE (SYMMETREL) (MAYO),1884813,CDM,300,RC,80375,HCPCS,Outpatient,,,142.5,85.5,,121.13,85,,96.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.04,80.03,,91.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.25,90,,102.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.4,88,,100.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.25,128.25,
CHROMATIN (NUCLEOSOMAL) AB  (MAYO),1886342,CDM,300,RC,86235,HCPCS,Outpatient,,,142.5,85.5,,121.13,85,,96.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.04,80.03,,91.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.28,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,128.25,90,,102.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.28,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.4,88,,100.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.55,128.25,
GLAUKOS 2ND STENT,110031,CDM,361,RC,0376T,HCPCS,Outpatient,,,142.65,85.59,,121.25,85,,97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.86,32.15,,36.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.16,80.03,,91.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.39,90,,102.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.86,32.15,,36.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.86,32.15,,36.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,125.53,88,,100.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.23,33.11,,37.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.86,128.39,
R TYPHI IGG  (MAYO),1886720,CDM,300,RC,86757,HCPCS,Outpatient,,,142.75,85.65,,121.34,85,,97.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.24,80.03,,91.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,128.48,90,,102.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.62,88,,100.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.35,128.48,
CORTISPORIN OPHTH SUSP 7.5 ML,297705,CDM,250,RC,,,Outpatient,,,143,85.8,,121.55,85,,97.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.97,32.15,,36.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.44,80.03,,91.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.7,90,,102.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.97,32.15,,36.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.97,32.15,,36.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,125.84,88,,100.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.35,33.11,,37.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.97,128.7,
"UROBILINOGEN, URINE  (MAYO)",1884580,CDM,300,RC,84580,HCPCS,Outpatient,,,143,85.8,,121.55,85,,97.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.44,80.03,,91.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.74,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,128.7,90,,102.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.74,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.84,88,,100.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.93,128.7,
EPOGEN (EPOETIN)*DIALYSIS*:3000UNITS INJ,293103,CDM,636,RC,Q4081,HCPCS,Outpatient,,,143,85.8,,121.55,85,,97.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.44,80.03,,91.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.7,90,,102.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.84,88,,100.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.71,128.7,
FUNGIZONE (amphotericin B) :50MG INJ,293341,CDM,636,RC,J0285,HCPCS,Outpatient,,,143.43,86.06,,121.92,85,,97.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.79,80.03,,91.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.09,90,,103.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,24.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.22,88,,100.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.36,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.62,129.09,
STREPTOMYCIN LEVEL (SERUM)   MAYO,1880300,CDM,300,RC,80299,HCPCS,Outpatient,,,143.5,86.1,,121.98,85,,97.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.84,80.03,,91.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,129.15,90,,103.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.28,88,,101.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,129.15,
"ADENOVIRUS, DNA-PCR EACH  (MAYO)",1886264,CDM,300,RC,87798,HCPCS,Outpatient,,,143.5,86.1,,121.98,85,,97.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.84,80.03,,91.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,129.15,90,,103.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.28,88,,101.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,129.15,
"ADENOVIRUS, CSF  (MAYO)",1887791,CDM,300,RC,87798,HCPCS,Outpatient,,,143.5,86.1,,121.98,85,,97.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,114.84,80.03,,91.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,129.15,90,,103.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.28,88,,101.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,129.15,
FIBROSURE APOLIPOPROTEIN  (MAYO),1883878,CDM,300,RC,82172,HCPCS,Outpatient,,,143.75,86.25,,122.19,85,,97.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.04,80.03,,92.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,129.38,90,,103.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,19.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.5,88,,101.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.49,129.38,
Blood test to measure B-12,1884253,CDM,300,RC,82607,HCPCS,Outpatient,,,143.75,86.25,,122.19,85,,97.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.04,80.03,,92.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,129.38,90,,103.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.5,88,,101.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.95,129.38,
THERAPEUTIC PROPHYLACTIC INJECT,96372,CDM,260,RC,96372,HCPCS,Outpatient,,,144.25,86.55,,122.61,85,,98.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.38,32.15,,37.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.44,80.03,,92.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,129.83,90,,103.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.38,32.15,,37.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,46.38,32.15,,37.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,126.94,88,,101.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.76,33.11,,38.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.38,129.83,
Cervical cancer screening test with interpretation,2188141,CDM,300,RC,88141,HCPCS,Outpatient,,,144.25,86.55,,122.61,85,,98.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.44,80.03,,92.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.83,90,,103.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,23.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.94,88,,101.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.78,129.83,
Cervical cancer screening test with interpretation,2188368,CDM,300,RC,88141,HCPCS,Outpatient,,,144.25,86.55,,122.61,85,,98.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.44,80.03,,92.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.83,90,,103.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,23.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.94,88,,101.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.78,129.83,
P/T EVAL LOW COMPLEXITY,3197161,CDM,424,RC,97161,HCPCS,Outpatient,,,144.32,86.59,,122.67,85,,98.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.4,32.15,,37.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.5,80.03,,92.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,97.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,129.89,90,,103.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.4,32.15,,37.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,46.4,32.15,,37.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127,88,,101.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.78,33.11,,38.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.4,129.89,
CATH COUDE 16FR 10ML 2-WAY,49450,CDM,270,RC,,,Outpatient,,,144.38,86.63,,122.72,85,,98.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.42,32.15,,37.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.55,80.03,,92.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.94,90,,103.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.42,32.15,,37.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.42,32.15,,37.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.05,88,,101.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.8,33.11,,38.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.42,129.94,
INTRALIPID 20%  500ML,296424,CDM,258,RC,,,Outpatient,,,144.46,86.68,,122.79,85,,98.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.44,32.15,,37.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.61,80.03,,92.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.01,90,,104.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.44,32.15,,37.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.44,32.15,,37.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.12,88,,101.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.83,33.11,,38.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.44,130.01,
SULFONYLUREAS   (MAYO),1880033,CDM,300,RC,82542,HCPCS,Outpatient,,,144.75,86.85,,123.04,85,,98.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.84,80.03,,92.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,130.28,90,,104.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.38,88,,101.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,130.28,
"ETHYLENE GLUCURONIDE SCREEN, U  (MAYO)",1882060,CDM,300,RC,80302,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.01,33.11,,38.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.62,130.5,
PROPAFENONE  (MAYO),1882489,CDM,300,RC,80299,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,130.5,
INTERLEUKIN 6 (IL-6)  (MAYO),1884803,CDM,300,RC,83520,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,130.5,
APPLICATION OF FINGER SPLINT;STATIC,1429130,CDM,450,RC,29130,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.01,33.11,,38.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.62,130.5,
Removal of ear wax from one or both ears,1469210,CDM,450,RC,69210,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.01,33.11,,38.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.62,130.5,
TRIMMING OF NONDYSTROPHIC NAILS ANY #,11719,CDM,761,RC,11719,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.01,33.11,,38.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.62,130.5,
DEBRIDEMENT OF NAILS BY ANY METHOD,11720,CDM,761,RC,11720,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.01,33.11,,38.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.62,130.5,
Removal of 6 or more nails,11721,CDM,761,RC,11721,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.01,33.11,,38.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.62,130.5,
BREVIBLOC (esmolol) 100MG/10ML VIAL,293107,CDM,250,RC,,,Outpatient,,,145.23,87.14,,123.45,85,,98.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.69,32.15,,37.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.23,80.03,,92.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.71,90,,104.57,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.69,32.15,,37.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.69,32.15,,37.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.8,88,,102.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.09,33.11,,38.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.69,130.71,
FORCEP ALLIGATOR 3 1/2  DISPOSABLE,4910084,CDM,270,RC,,,Outpatient,,,145.25,87.15,,123.46,85,,98.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.7,32.15,,37.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.24,80.03,,92.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.73,90,,104.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.7,32.15,,37.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.7,32.15,,37.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.82,88,,102.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.09,33.11,,38.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.7,130.73,
VITAMIN K  (MAYO),1884597,CDM,300,RC,84597,HCPCS,Outpatient,,,145.25,87.15,,123.46,85,,98.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,116.24,80.03,,92.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,130.73,90,,104.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.82,88,,102.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.24,130.73,
Outpatient visit of established patient not requiring a physician,6004,CDM,450,RC,99211,HCPCS,Outpatient,,,145.96,87.58,,124.07,85,,99.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.93,32.15,,37.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.81,80.03,,93.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.36,90,,105.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.93,32.15,,37.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.93,32.15,,37.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.44,88,,102.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.33,33.11,,38.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.93,131.36,
LEVEL 1 ED VISIT,14005,CDM,450,RC,99281,HCPCS,Outpatient,,,145.96,87.58,,124.07,85,,99.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.81,80.03,,93.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.98,102,,,fee schedule,Pays at 102% of CMS APC rate,131.36,90,,105.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.98,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.44,88,,102.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,116.81,385,
IV THERAPY ADDITIONAL NEW DRUG,96367,CDM,260,RC,96367,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.66,102,,,fee schedule,Pays at 102% of CMS APC rate,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.66,100,,,fee schedule,Pays at 100% of CMS APC rate,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
SIX MINUTE WALK,457,CDM,460,RC,94618,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
Immunization administration by a medical assistant or nurse,11021,CDM,771,RC,90471,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
VACCINE ADMINISTRATION EA ADDITIONAL,14051,CDM,771,RC,90472,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
Immunization administration by a medical assistant or nurse,62004,CDM,771,RC,90471,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
Immunization administration by a medical assistant or nurse,62006,CDM,771,RC,90471,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
Immunization administration by a medical assistant or nurse,296002,CDM,771,RC,90471,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
"CYCLIC AMP, URINARY EXCRETION  (MAYO)",1882066,CDM,300,RC,82030,HCPCS,Outpatient,,,146.5,87.9,,124.53,85,,99.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.24,80.03,,93.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.31,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,131.85,90,,105.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.31,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,32.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,128.92,88,,103.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.45,131.85,
"CANDIDA AB IgG,A & M  (MAYO)",1886628,CDM,300,RC,86628,HCPCS,Outpatient,,,146.5,87.9,,124.53,85,,99.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.24,80.03,,93.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,131.85,90,,105.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,128.92,88,,103.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.55,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.1,131.85,
Blood test for an STD,1882702,CDM,300,RC,87661,HCPCS,Outpatient,,,146.65,87.99,,124.65,85,,99.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.36,80.03,,93.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,131.99,90,,105.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.05,88,,103.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.42,131.99,
P/T NEOPRENE TENNIS ELBOW STRAP,397,CDM,424,RC,L3700,HCPCS,Outpatient,,,146.75,88.05,,124.74,85,,99.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.18,32.15,,37.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.44,80.03,,93.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.08,90,,105.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.18,32.15,,37.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.18,32.15,,37.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.14,88,,103.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.59,33.11,,38.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.18,132.08,
O/T NEOPRENE TENNIS ELBOW STRAP,396,CDM,430,RC,L3700,HCPCS,Outpatient,,,146.75,88.05,,124.74,85,,99.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.18,32.15,,37.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.44,80.03,,93.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.08,90,,105.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.18,32.15,,37.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.18,32.15,,37.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.14,88,,103.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.59,33.11,,38.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.18,132.08,
ANMED HPV,2188395,CDM,300,RC,87623,HCPCS,Outpatient,,,146.88,88.13,,124.85,85,,99.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.55,80.03,,94.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,132.19,90,,105.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.25,88,,103.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.25,132.19,
ACETYLCHOLINE RECEPTOR BINDING AB (MAYO),1883500,CDM,300,RC,83519,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,132.3,
NEURONAL (V-G) K+ CHANNEL AB (MAYO),1884296,CDM,300,RC,83519,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,132.3,
N-TYPE CALCIUM CHANNEL AB (MAYO),1884297,CDM,300,RC,83519,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,132.3,
P/Q-TYPE CALCIUM CHANNEL AB (MAYO),1884298,CDM,300,RC,83519,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,132.3,
ACHR GANGLIONIC NEURONAL AB (MAYO),1884299,CDM,300,RC,83519,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,132.3,
"DRVVT, MIX  LUPUS ANTICOAG PROFIL (MAYO)",1885217,CDM,300,RC,85613,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.03,132.3,
P/T MIN DEBRIDEMENT,3955,CDM,420,RC,97799,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.26,32.15,,37.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.26,32.15,,37.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.26,32.15,,37.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.67,33.11,,38.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.26,132.3,
P/T MOD DEBRIDEMENT,3956,CDM,420,RC,97799,HCPCS,Outpatient,,,147,88.2,,124.95,85,,99.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.26,32.15,,37.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.64,80.03,,94.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,105.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.26,32.15,,37.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.26,32.15,,37.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.36,88,,103.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.67,33.11,,38.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.26,132.3,
ISOVUE 250 BT 150ML,265025,CDM,250,RC,,,Outpatient,,,147.5,88.5,,125.38,85,,100.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.42,32.15,,37.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.04,80.03,,94.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.75,90,,106.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.42,32.15,,37.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.42,32.15,,37.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.8,88,,103.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.84,33.11,,39.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.42,132.75,
CRUTCH TALL 5'10  - 6'6  300LB,491198,CDM,270,RC,,,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
CRUTCH YOUTH,491200,CDM,270,RC,,,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
PHY/QHP PULM W/O MNTR,6594625,CDM,948,RC,94625,HCPCS,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.09,102,,,fee schedule,Pays at 102% of CMS APC rate,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.09,100,,,fee schedule,Pays at 100% of CMS APC rate,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
PHY/QHP PULM W/ MNTR,6594626,CDM,948,RC,94626,HCPCS,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.09,102,,,fee schedule,Pays at 102% of CMS APC rate,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.09,100,,,fee schedule,Pays at 100% of CMS APC rate,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
ANAEROBIC SENSITIVITY BATTERY (MAYO),1884811,CDM,300,RC,87181,HCPCS,Outpatient,,,148.25,88.95,,126.01,85,,100.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,118.64,80.03,,94.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,133.43,90,,106.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,130.46,88,,104.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,133.43,
TEQUIN 400MG/200ML PB *DISCONTINUED*,293513,CDM,250,RC,J1590,HCPCS,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
"DRESSING, VAC GRANFOAM MEDIUM",43836,CDM,270,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
ELECTRODE FAST PATCH DEFIBRILLATION,49098,CDM,270,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
CATHETER TROCAR 8FR 2.7MM,49607,CDM,270,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
CATHETER TROCAR 10FR 3.3MM,49608,CDM,270,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
CATHETER TROCAR 12FR 4.0MM,49609,CDM,270,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
KIT CLOSED WOUND SUCTION MEDIUM 1/8,491484,CDM,270,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
KIT CLOSED WOUND SUCTION SMALL 3/32,491490,CDM,270,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
HUMAN ALBUMIN 25G,2096394,CDM,636,RC,P9046,HCPCS,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.65,102,,,fee schedule,Pays at 102% of CMS APC rate,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,100,,,fee schedule,Pays at 100% of CMS APC rate,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.23,133.88,
FETAL MON PER HOUR AFTER 1ST HOUR,6031,CDM,721,RC,,,Outpatient,,,148.75,89.25,,126.44,85,,101.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.04,80.03,,95.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,90,,107.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.82,32.15,,38.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.9,88,,104.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.25,33.11,,39.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.82,133.88,
Test of a wound for type of bacterial infection,1887087,CDM,300,RC,87077,HCPCS,Outpatient,,,149,89.4,,126.65,85,,101.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.24,80.03,,95.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,134.1,90,,107.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,131.12,88,,104.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.16,134.1,
.OXYHOOD,30085,CDM,270,RC,,,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
Radiologic examination of the finger(s),22062,CDM,320,RC,73140,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
HIP 1V LT,22063,CDM,320,RC,73501,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
Radiologic examination of the toe(s),22078,CDM,320,RC,73660,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
Radiologic examination of the knee with 1 or 2 views,22096,CDM,320,RC,73560,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
PORT X-TABLE CERVICAL 1V,22135,CDM,320,RC,72020,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
Radiologic examination of the heel,22148,CDM,320,RC,73650,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
Radiologic examination of the heel,22149,CDM,320,RC,73650,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
Radiologic examination of the finger(s),22188,CDM,320,RC,73140,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
CERVICAL LIMITED 1 VIEW,22337,CDM,320,RC,72020,HCPCS,Outpatient,,,149.25,89.55,,126.86,85,,101.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.44,80.03,,95.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,134.33,90,,107.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,47.98,32.15,,38.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.34,88,,105.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.42,33.11,,39.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.98,134.33,
SET FLUID/BLOOD WARMING,494401,CDM,270,RC,,,Outpatient,,,149.5,89.7,,127.08,85,,101.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.06,32.15,,38.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.64,80.03,,95.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.55,90,,107.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.06,32.15,,38.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.06,32.15,,38.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.56,88,,105.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.5,33.11,,39.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.06,134.55,
AUGMENTIN (amox/clav) 400MG/5ML : 100 ML,294077,CDM,250,RC,,,Outpatient,,,149.55,89.73,,127.12,85,,101.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.08,32.15,,38.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.68,80.03,,95.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.6,90,,107.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.08,32.15,,38.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.08,32.15,,38.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.6,88,,105.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.52,33.11,,39.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.08,134.6,
11-DEOXYCORTISOL  (MAYO),1882634,CDM,300,RC,82634,HCPCS,Outpatient,,,149.75,89.85,,127.29,85,,101.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.84,80.03,,95.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,29.86,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,134.78,90,,107.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.86,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,36.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,131.78,88,,105.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.81,134.78,
VENTOLIN/PROVENTIL (ALBUTEROL) INHALER,292047,CDM,250,RC,J3535,HCPCS,Outpatient,,,149.85,89.91,,127.37,85,,101.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.18,32.15,,38.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.92,80.03,,95.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.87,90,,107.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.18,32.15,,38.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.18,32.15,,38.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.87,88,,105.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.62,33.11,,39.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.18,134.87,
CUSTOMIZED DYNAMIC SPLINT,313003,CDM,270,RC,,,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
TUBE ENDO 7.5MM LMA FASTRACH DISPOSABLE,491953,CDM,270,RC,,,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
BIOPSY NEEDLE 14G X 6  TRU CUT,492704,CDM,270,RC,,,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
"OPIATES, QT  (MAYO)",1882210,CDM,300,RC,80364,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.47,135,
BETA 2 TRANSFERRIN  (MAYO),1882234,CDM,300,RC,86335,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,29.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,36.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.9,135,
OUT-PATIENT DRUG SCREEN,1882658,CDM,300,RC,80301,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
Radiologic examination of the pelvis,22200,CDM,320,RC,72170,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
Chemotherapy infusion-each additional hour,96415,CDM,335,RC,96415,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.66,102,,,fee schedule,Pays at 102% of CMS APC rate,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.66,100,,,fee schedule,Pays at 100% of CMS APC rate,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
A technique used by physical therapists to restore normal body movement patterns,3421,CDM,430,RC,97112,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
"HISTAMINE, URINE  (MAYO)",1883089,CDM,300,RC,83088,HCPCS,Outpatient,,,150.25,90.15,,127.71,85,,102.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.25,80.03,,96.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,135.23,90,,108.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132.22,88,,105.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.13,135.23,
VANTIN  (cefpodoxime)100MG/5ML : 100ML,294051,CDM,250,RC,,,Outpatient,,,150.64,90.38,,128.04,85,,102.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.43,32.15,,38.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.56,80.03,,96.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.58,90,,108.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.43,32.15,,38.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.43,32.15,,38.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.56,88,,106.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.88,33.11,,39.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.43,135.58,
BSS PLUS 500ML,297754,CDM,250,RC,,,Outpatient,,,150.64,90.38,,128.04,85,,102.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.43,32.15,,38.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.56,80.03,,96.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.58,90,,108.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.43,32.15,,38.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.43,32.15,,38.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.56,88,,106.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.88,33.11,,39.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.43,135.58,
GOWN BAIR PAWS FLEX XL,499859,CDM,270,RC,,,Outpatient,,,150.75,90.45,,128.14,85,,102.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.47,32.15,,38.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.65,80.03,,96.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.68,90,,108.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.47,32.15,,38.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.75,,,,Other,Not Separately reimbursable,48.47,32.15,,38.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.66,88,,106.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.91,33.11,,39.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.47,135.68,
Test to predict likelihood of gestational diabetes,1882956,CDM,300,RC,82951,HCPCS,Outpatient,,,150.75,90.45,,128.14,85,,102.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.65,80.03,,96.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,135.68,90,,108.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132.66,88,,106.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,135.68,
CATHETER REMOVAL/CHANGE,1447525,CDM,450,RC,,,Outpatient,,,150.75,90.45,,128.14,85,,102.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.47,32.15,,38.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.65,80.03,,96.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.68,90,,108.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.47,32.15,,38.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.47,32.15,,38.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.66,88,,106.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.91,33.11,,39.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.47,135.68,
DHEA  (MAYO),1884875,CDM,300,RC,82626,HCPCS,Outpatient,,,150.99,90.59,,128.34,85,,102.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.84,80.03,,96.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,25.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,135.89,90,,108.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,31.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132.87,88,,106.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,31.78,135.89,
IM ANTIBIOTIC INJ,4010,CDM,260,RC,96372,HCPCS,Outpatient,,,151,90.6,,128.35,85,,102.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.85,80.03,,96.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,135.9,90,,108.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.88,88,,106.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50,33.11,,40,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.55,135.9,
INJECTION FEE SC IM,6014,CDM,260,RC,96372,HCPCS,Outpatient,,,151,90.6,,128.35,85,,102.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.85,80.03,,96.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,135.9,90,,108.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.88,88,,106.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50,33.11,,40,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.55,135.9,
"INJECTION, IM",1490788,CDM,260,RC,96372,HCPCS,Outpatient,,,151,90.6,,128.35,85,,102.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.85,80.03,,96.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,135.9,90,,108.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.88,88,,106.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50,33.11,,40,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.55,135.9,
HUMAN T-CELL TYPE I & II (MAYO),1884700,CDM,300,RC,86790,HCPCS,Outpatient,,,151,90.6,,128.35,85,,102.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.85,80.03,,96.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,135.9,90,,108.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132.88,88,,106.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,135.9,
Immunization administration by a medical assistant or nurse,14014,CDM,771,RC,90471,HCPCS,Outpatient,,,151,90.6,,128.35,85,,102.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.85,80.03,,96.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,135.9,90,,108.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,48.55,32.15,,38.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.88,88,,106.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50,33.11,,40,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.55,135.9,
BINDER ABDOMINAL 12  46-62 INCH,491147,CDM,270,RC,,,Outpatient,,,152.5,91.5,,129.63,85,,103.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.03,32.15,,39.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.05,80.03,,97.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.25,90,,109.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.03,32.15,,39.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.03,32.15,,39.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.2,88,,107.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.49,33.11,,40.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.03,137.25,
Testing for presence of drug,1882003,CDM,300,RC,80307,HCPCS,Outpatient,,,152.73,91.64,,129.82,85,,103.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.23,80.03,,97.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,137.46,90,,109.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,134.4,88,,107.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.16,137.46,
Testing for presence of drug,1882011,CDM,300,RC,80307,HCPCS,Outpatient,,,152.73,91.64,,129.82,85,,103.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.23,80.03,,97.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,137.46,90,,109.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,134.4,88,,107.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.16,137.46,
O/T EVAL LOW COMPLEXITY,5997165,CDM,434,RC,97165,HCPCS,Outpatient,,,152.73,91.64,,129.82,85,,103.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.1,32.15,,39.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.23,80.03,,97.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,97.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,137.46,90,,109.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.1,32.15,,39.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,49.1,32.15,,39.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.4,88,,107.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.57,33.11,,40.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.1,137.46,
TRANSCUTANEOUS MONITOR,30251,CDM,410,RC,93923,HCPCS,Outpatient,,,152.75,91.65,,129.84,85,,103.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.25,80.03,,97.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,137.48,90,,109.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.42,88,,107.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.58,33.11,,40.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.11,137.48,
P/T EMG BIOFEEDBACK,335,CDM,420,RC,90901,HCPCS,Outpatient,,,152.75,91.65,,129.84,85,,103.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.25,80.03,,97.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.78,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,137.48,90,,109.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.78,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.42,88,,107.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.58,33.11,,40.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.11,137.48,
O/T EMG BIOFEEDBACK,3351,CDM,430,RC,90901,HCPCS,Outpatient,,,152.75,91.65,,129.84,85,,103.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.25,80.03,,97.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.78,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,137.48,90,,109.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18.78,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.42,88,,107.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.58,33.11,,40.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.11,137.48,
UNLISTED THERAPEUTIC OR DIAGNOSTIC INJEC,1490799,CDM,450,RC,,,Outpatient,,,152.75,91.65,,129.84,85,,103.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.25,80.03,,97.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.48,90,,109.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.11,32.15,,39.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.42,88,,107.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.58,33.11,,40.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.11,137.48,
ZYMAR (gatifloxacin) OPHTH SOL 5 ML,291037,CDM,250,RC,,,Outpatient,,,153,91.8,,130.05,85,,104.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.45,80.03,,97.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.7,90,,110.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.64,88,,107.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.66,33.11,,40.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.19,137.7,
ZOVIRAX (acyclovir) 5% CR 2GM,298064,CDM,250,RC,,,Outpatient,,,153,91.8,,130.05,85,,104.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.45,80.03,,97.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.7,90,,110.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.64,88,,107.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.66,33.11,,40.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.19,137.7,
PAD CHAIR CAPTIAN,4999054,CDM,270,RC,,,Outpatient,,,153,91.8,,130.05,85,,104.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.45,80.03,,97.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.7,90,,110.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.19,32.15,,39.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.64,88,,107.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.66,33.11,,40.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.19,137.7,
FDP  (MAYO),1885362,CDM,300,RC,85362,HCPCS,Outpatient,,,153,91.8,,130.05,85,,104.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,122.45,80.03,,97.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,137.7,90,,110.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.66,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,134.64,88,,107.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.66,137.7,
MATERNITY BACK SUPPORT,461,CDM,420,RC,L1499,HCPCS,Outpatient,,,153.5,92.1,,130.48,85,,104.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.35,32.15,,39.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.85,80.03,,98.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.15,90,,110.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.35,32.15,,39.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.35,32.15,,39.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.08,88,,108.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.82,33.11,,40.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.35,138.15,
"Radiologic examination of the neck/spine, 4-5 views",22034,CDM,320,RC,72050,HCPCS,Outpatient,,,153.75,92.25,,130.69,85,,104.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.43,32.15,,39.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.05,80.03,,98.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,138.38,90,,110.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.43,32.15,,39.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,49.43,32.15,,39.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.3,88,,108.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.91,33.11,,40.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.43,138.38,
PREGNELONE  (MAYO),1884140,CDM,300,RC,84140,HCPCS,Outpatient,,,154,92.4,,130.9,85,,104.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,123.25,80.03,,98.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,138.6,90,,110.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,135.52,88,,108.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26,138.6,
Blood test to measure a type of estrogen in the blood,1884807,CDM,300,RC,82670,HCPCS,Outpatient,,,154,92.4,,130.9,85,,104.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,123.25,80.03,,98.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,138.6,90,,110.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,35.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,135.52,88,,108.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.19,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,35.14,138.6,
PANAFIL 1OZ,298067,CDM,250,RC,,,Outpatient,,,154.25,92.55,,131.11,85,,104.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.59,32.15,,39.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.45,80.03,,98.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.83,90,,111.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.59,32.15,,39.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.59,32.15,,39.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.74,88,,108.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.07,33.11,,40.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.59,138.83,
HGB A2 AND F  (MAYO),1883021,CDM,300,RC,83021,HCPCS,Outpatient,,,154.25,92.55,,131.11,85,,104.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,123.45,80.03,,98.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,138.83,90,,111.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,135.74,88,,108.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,138.83,
BELT TRACTION PELVIC XLARGE,491094,CDM,270,RC,,,Outpatient,,,154.5,92.7,,131.33,85,,105.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.65,80.03,,98.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.05,90,,111.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.96,88,,108.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.15,33.11,,40.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.67,139.05,
BELT TRACTION PELVIC MED/LG,491096,CDM,270,RC,,,Outpatient,,,154.5,92.7,,131.33,85,,105.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.65,80.03,,98.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.05,90,,111.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.96,88,,108.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.15,33.11,,40.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.67,139.05,
BELT TRACTION PELVIC SMALL,491099,CDM,270,RC,,,Outpatient,,,154.5,92.7,,131.33,85,,105.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.65,80.03,,98.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.05,90,,111.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.96,88,,108.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.15,33.11,,40.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.67,139.05,
CATH ADAPTER TYPE II CO-PACK W/CATH ADAP,4980082,CDM,270,RC,,,Outpatient,,,154.5,92.7,,131.33,85,,105.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.65,80.03,,98.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.05,90,,111.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.67,32.15,,39.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.96,88,,108.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.15,33.11,,40.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.67,139.05,
MITYONE VACUUM-ASSIST DEL MUSHROOM CUP,49333,CDM,270,RC,,,Outpatient,,,155,93,,131.75,85,,105.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.83,32.15,,39.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.05,80.03,,99.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.5,90,,111.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.83,32.15,,39.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.83,32.15,,39.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.4,88,,109.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.32,33.11,,41.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.83,139.5,
DO NOT USE,311203,CDM,420,RC,97022,HCPCS,Outpatient,,,155,93,,131.75,85,,105.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.83,32.15,,39.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.05,80.03,,99.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.27,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,139.5,90,,111.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.83,32.15,,39.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16.27,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,49.83,32.15,,39.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.4,88,,109.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.32,33.11,,41.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.83,139.5,
XYLOC 4% (LIDOCAINE) TOP SOLN: 50ML,293221,CDM,250,RC,,,Outpatient,,,155.14,93.08,,131.87,85,,105.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.88,32.15,,39.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.16,80.03,,99.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.63,90,,111.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.88,32.15,,39.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.88,32.15,,39.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.52,88,,109.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.37,33.11,,41.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.88,139.63,
HIP AP/LAT 2V LT,22064,CDM,320,RC,73502,HCPCS,Outpatient,,,155.19,93.11,,131.91,85,,105.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.89,32.15,,39.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.2,80.03,,99.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,139.67,90,,111.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.89,32.15,,39.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,49.89,32.15,,39.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.57,88,,109.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.38,33.11,,41.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.89,139.67,
HIP AP/LAT 2V RT,22285,CDM,320,RC,73502,HCPCS,Outpatient,,,155.19,93.11,,131.91,85,,105.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.89,32.15,,39.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.2,80.03,,99.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,139.67,90,,111.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.89,32.15,,39.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,49.89,32.15,,39.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.57,88,,109.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.38,33.11,,41.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.89,139.67,
OUT-PATIENT DRUG SCREEN II  W/ALCOHOL,1882653,CDM,300,RC,80304,HCPCS,Outpatient,,,155.25,93.15,,131.96,85,,105.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.25,80.03,,99.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.73,90,,111.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.62,88,,109.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.4,33.11,,41.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.91,139.73,
"QL, MULTIPLE DRUG CLASS PER ENCOUNTER",1889997,CDM,300,RC,G0431,HCPCS,Outpatient,,,155.25,93.15,,131.96,85,,105.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.25,80.03,,99.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.73,90,,111.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.62,88,,109.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.4,33.11,,41.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.91,139.73,
Radiologic examination of the finger(s),22189,CDM,320,RC,73140,HCPCS,Outpatient,,,155.25,93.15,,131.96,85,,105.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.25,80.03,,99.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,139.73,90,,111.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.62,88,,109.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.4,33.11,,41.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.91,139.73,
EMERGENCY ROOM/EXTENSIVE,14000,CDM,450,RC,99282,HCPCS,Outpatient,,,155.25,93.15,,131.96,85,,105.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.25,80.03,,99.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,133.91,102,,,fee schedule,Pays at 102% of CMS APC rate,139.73,90,,111.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,133.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.62,88,,109.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,124.25,385,
"APLIGRAF, PER 1 SQ CM",844101,CDM,636,RC,Q4101,HCPCS,Outpatient,,,155.25,93.15,,131.96,85,,105.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.25,80.03,,99.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.73,90,,111.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.91,32.15,,39.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.62,88,,109.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.4,33.11,,41.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.91,139.73,
NEEDLES 3.5 FORAMEN,4999931,CDM,270,RC,,,Outpatient,,,155.75,93.45,,132.39,85,,105.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,50.07,32.15,,40.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.65,80.03,,99.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.18,90,,112.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,50.07,32.15,,40.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,50.07,32.15,,40.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.06,88,,109.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.57,33.11,,41.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,50.07,140.18,
NEEDLES 5.0 FORAMEN,4999932,CDM,270,RC,,,Outpatient,,,155.75,93.45,,132.39,85,,105.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,50.07,32.15,,40.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.65,80.03,,99.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.18,90,,112.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,50.07,32.15,,40.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,50.07,32.15,,40.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.06,88,,109.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.57,33.11,,41.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,50.07,140.18,
NON-GYN PREP TECHNICAL FEE,2188104,CDM,310,RC,88104,HCPCS,Outpatient,,,156.25,93.75,,132.81,85,,106.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.05,80.03,,100.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,140.63,90,,112.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,137.5,88,,110,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,42.68,140.63,
PHENCYCLIDINE CONFIRMATION  (MAYO),1882671,CDM,300,RC,83992,HCPCS,Outpatient,,,156.75,94.05,,133.24,85,,106.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.45,80.03,,100.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.08,90,,112.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,18.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,137.94,88,,110.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.49,141.08,
ALBUMIN 25%: 12.5GM/50ML,293330,CDM,250,RC,,,Outpatient,,,156.82,94.09,,133.3,85,,106.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,50.42,32.15,,40.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,125.5,80.03,,100.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.14,90,,112.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,50.42,32.15,,40.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,50.42,32.15,,40.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138,88,,110.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.92,33.11,,41.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,50.42,141.14,
LEPTOSPIRA IGM  (MAYO),1880668,CDM,300,RC,86720,HCPCS,Outpatient,,,157.08,94.25,,133.52,85,,106.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,125.71,80.03,,100.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.52,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,141.37,90,,113.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.52,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,138.23,88,,110.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.59,141.37,
"BILIRUBIN, BODY FLUID  (MAYO)",1882978,CDM,300,RC,82247,HCPCS,Outpatient,,,157.5,94.5,,133.88,85,,107.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.05,80.03,,100.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,141.75,90,,113.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,138.6,88,,110.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.32,141.75,
PORT ABDOMEN SINGLE AP,22206,CDM,320,RC,74018,HCPCS,Outpatient,,,157.85,94.71,,134.17,85,,107.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,50.75,32.15,,40.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,126.33,80.03,,101.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,142.07,90,,113.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,50.75,32.15,,40.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,50.75,32.15,,40.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.91,88,,111.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.26,33.11,,41.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,50.75,142.07,
"LYME DISEASE, PCR,   (MAYO)",1887476,CDM,300,RC,87476,HCPCS,Outpatient,,,158,94.8,,134.3,85,,107.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.45,80.03,,101.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,142.2,90,,113.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,139.04,88,,111.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,142.2,
VORICONAZOLE (MAYO),1880038,CDM,300,RC,80299,HCPCS,Outpatient,,,158.5,95.1,,134.73,85,,107.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.85,80.03,,101.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,142.65,90,,114.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,139.48,88,,111.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,142.65,
EHRLICHIA CHAFFIENSIS AB  (MAYO),1886753,CDM,300,RC,86666,HCPCS,Outpatient,,,158.5,95.1,,134.73,85,,107.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.85,80.03,,101.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,142.65,90,,114.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,139.48,88,,111.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.8,142.65,
DRESSING SIMPLACE SMALL VAC KIT,49685,CDM,270,RC,,,Outpatient,,,158.75,95.25,,134.94,85,,107.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.04,32.15,,40.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.05,80.03,,101.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.88,90,,114.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.04,32.15,,40.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.04,32.15,,40.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.7,88,,111.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.56,33.11,,42.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.04,142.88,
IMMUNOFIXATION-OTHER FLDS  (MAYO),1886325,CDM,300,RC,86325,HCPCS,Outpatient,,,158.75,95.25,,134.94,85,,107.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.05,80.03,,101.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,142.88,90,,114.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,139.7,88,,111.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.12,142.88,
CYSTOGRAFIN,225008,CDM,255,RC,,,Outpatient,,,159.18,95.51,,135.3,85,,108.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.18,32.15,,40.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.39,80.03,,101.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.26,90,,114.61,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.18,32.15,,40.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.18,32.15,,40.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.08,88,,112.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.7,33.11,,42.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.18,143.26,
PROBE DISPOSABLE OXIMETER,49800,CDM,270,RC,,,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
Radiologic examination of the pelvis,22043,CDM,320,RC,72170,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
Radiologic examination of the forearm,22058,CDM,320,RC,73090,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
Radiologic examination of the collar bone,22137,CDM,320,RC,73000,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
Radiologic examination of the knee with 1 or 2 views,22147,CDM,320,RC,73560,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
Radiologic examination of the ankle with 2 views,22175,CDM,320,RC,73600,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
Radiologic examination of the forearm,22195,CDM,320,RC,73090,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
Radiologic examination of the ankle with 2 views,22208,CDM,320,RC,73600,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
DOUBLE SET-UP CHARGE O/P,11020,CDM,360,RC,,,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
"DERMAGRAFT, PER 1 SQ CM",844106,CDM,636,RC,Q4106,HCPCS,Outpatient,,,159.75,95.85,,135.79,85,,108.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.36,32.15,,41.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.85,80.03,,102.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.78,90,,115.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.36,32.15,,41.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.36,32.15,,41.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.58,88,,112.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.89,33.11,,42.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.36,143.78,
AUGMENTIN (AMOX/CLAV) 250MG/5ML : 100ML,295138,CDM,250,RC,,,Outpatient,,,159.91,95.95,,135.92,85,,108.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.41,32.15,,41.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.98,80.03,,102.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.92,90,,115.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.41,32.15,,41.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.41,32.15,,41.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.72,88,,112.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.95,33.11,,42.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.41,143.92,
IMMOBILIZER SHOULDER MEDIUM VELPEAU,491155,CDM,270,RC,,,Outpatient,,,160,96,,136,85,,108.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.44,32.15,,41.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.05,80.03,,102.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,115.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.44,32.15,,41.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.44,32.15,,41.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.8,88,,112.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.98,33.11,,42.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.44,144,
URINE METABOLIC SCREEN,1882130,CDM,300,RC,82127,HCPCS,Outpatient,,,160,96,,136,85,,108.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,128.05,80.03,,102.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.46,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,144,90,,115.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.46,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.8,88,,112.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.43,144,
..ERA,1888303,CDM,300,RC,84233,HCPCS,Outpatient,,,160,96,,136,85,,108.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,128.05,80.03,,102.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,89.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,144,90,,115.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,89.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,80.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.8,88,,112.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,80.99,144,
A technique used by physical therapists to restore normal body movement patterns,593028,CDM,430,RC,97112,HCPCS,Outpatient,,,160.3,96.18,,136.26,85,,109.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.54,32.15,,41.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.29,80.03,,102.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.85,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,144.27,90,,115.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.54,32.15,,41.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.85,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,51.54,32.15,,41.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.06,88,,112.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.08,33.11,,42.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.54,144.27,
PATIENT EVALUATION,530301,CDM,540,RC,,,Outpatient,,,160.3,96.18,,136.26,85,,109.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.54,32.15,,41.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.29,80.03,,102.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.27,90,,115.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.54,32.15,,41.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.54,32.15,,41.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.06,88,,112.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.08,33.11,,42.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.54,144.27,
NASAL BONES,22008,CDM,320,RC,70160,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
SINUSES PARANASAL 3V,22012,CDM,320,RC,70220,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
NECK SOFT TISSUE,22017,CDM,320,RC,70360,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
3 views,22022,CDM,320,RC,71047,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
STERNUM 2V,22029,CDM,320,RC,71120,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination of the neck/spine, 2-3 views",22032,CDM,320,RC,72040,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the lower leg,22041,CDM,320,RC,73590,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
SACRUM AND COCCYX 2V,22046,CDM,320,RC,72220,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
OR SHOULDER AP 1V,22048,CDM,320,RC,73020,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
SHOULDER AP 1V LT,22051,CDM,320,RC,73020,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 2 views",22056,CDM,320,RC,73070,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PELVIS /HIPS PEDS 2V,22068,CDM,320,RC,73502,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 1 or 2 views,22070,CDM,320,RC,73560,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 1 or 2 views,22071,CDM,320,RC,73560,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the heel,22077,CDM,320,RC,73650,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Up to 3 views,22103,CDM,320,RC,73110,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 3 views,22108,CDM,320,RC,73562,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Single view,22133,CDM,320,RC,71045,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the shoulder,22140,CDM,320,RC,73030,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
OR HUMERUS 2V LT,22141,CDM,320,RC,73060,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
OR HUMERUS 2V RT,22142,CDM,320,RC,73060,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 1 or 2 views,22146,CDM,320,RC,73560,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the lower leg,22157,CDM,320,RC,73590,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
FEMUR BILAT 2V,22159,CDM,320,RC,73552,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
3 or more views,22167,CDM,320,RC,73100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the forearm,22169,CDM,320,RC,73090,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
MANDIBLE <4V,22174,CDM,320,RC,70100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
RIBS UNILAT 2V,22176,CDM,320,RC,71100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
OR ABDOMEN,22179,CDM,320,RC,74018,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the ankle with 2 views,22180,CDM,320,RC,73600,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the ankle with 2 views,22181,CDM,320,RC,73600,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 2 views",22184,CDM,320,RC,73070,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 2 views",22185,CDM,320,RC,73070,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
OR FEMUR 2V LT,22186,CDM,320,RC,73552,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
OR FEMUR 2V RT,22187,CDM,320,RC,73552,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, foot; 2 views",22193,CDM,320,RC,73620,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, foot; 2 views",22194,CDM,320,RC,73620,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the forearm,22196,CDM,320,RC,73090,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the ankle with 3 views,22207,CDM,320,RC,73610,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"2 views, front and back",22212,CDM,320,RC,71046,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT FEMUR 2V LT,22218,CDM,320,RC,73552,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
X-ray of the hand with 3 or more views,22223,CDM,320,RC,73130,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT HIP AP/LAT 2V LT,22224,CDM,320,RC,73502,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 1 or 2 views,22230,CDM,320,RC,73560,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT NECK SOFT TISSUE,22234,CDM,320,RC,70360,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT SHOULDER AP 1V LT,22244,CDM,320,RC,73020,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the shoulder,22245,CDM,320,RC,73030,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the lower leg,22255,CDM,320,RC,73590,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Up to 3 views,22258,CDM,320,RC,73110,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 2 views",22259,CDM,320,RC,73070,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the lower leg,22261,CDM,320,RC,73590,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 2 views",22274,CDM,320,RC,73070,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 3 or more views",22276,CDM,320,RC,73080,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, foot; 2 views",22279,CDM,320,RC,73620,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
HIP 1V RT,22284,CDM,320,RC,73501,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
HUMERUS 2V RT,22286,CDM,320,RC,73060,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 1 or 2 views,22289,CDM,320,RC,73560,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the heel,22297,CDM,320,RC,73650,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 1 or 2 views,22298,CDM,320,RC,73560,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 3 or more views",22321,CDM,320,RC,73080,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, foot; 2 views",22323,CDM,320,RC,73620,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination of the neck/spine, 2-3 views",22325,CDM,320,RC,72040,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 2 views",22326,CDM,320,RC,73070,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT FEMUR 2V RT,22327,CDM,320,RC,73552,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the finger(s),22328,CDM,320,RC,73140,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the foot with 3 or more views,22329,CDM,320,RC,73630,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the forearm,22333,CDM,320,RC,73090,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
X-ray of the hand with 3 or more views,22349,CDM,320,RC,73130,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT HIP AP/LAT 2V RT,22350,CDM,320,RC,73502,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT HIP UNILAT 1V RT,22351,CDM,320,RC,73501,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the knee with 1 or 2 views,22353,CDM,320,RC,73560,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
PORT SHOULDER AP 1V RT,22356,CDM,320,RC,73020,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the shoulder,22357,CDM,320,RC,73030,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the lower leg,22358,CDM,320,RC,73590,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Up to 3 views,22360,CDM,320,RC,73110,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
SHOULDER AP 1V RT,22361,CDM,320,RC,73020,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the toe(s),22364,CDM,320,RC,73660,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
3 or more views,22365,CDM,320,RC,73100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the toe(s),22371,CDM,320,RC,73660,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the toe(s),22372,CDM,320,RC,73660,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the toe(s),22373,CDM,320,RC,73660,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
3 or more views,22374,CDM,320,RC,73100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
3 or more views,22375,CDM,320,RC,73100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
"Radiologic examination, elbow; 3 or more views",22380,CDM,320,RC,73080,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the toe(s),22386,CDM,320,RC,73660,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the toe(s),22387,CDM,320,RC,73660,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the heel,22389,CDM,320,RC,73650,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
3 or more views,22401,CDM,320,RC,73100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
3 or more views,22402,CDM,320,RC,73100,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Radiologic examination of the shoulder,22453,CDM,320,RC,73030,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Up to 3 views,22500,CDM,320,RC,73110,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
Up to 3 views,22501,CDM,320,RC,73110,HCPCS,Outpatient,,,160.5,96.3,,136.43,85,,109.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.45,80.03,,102.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,144.45,90,,115.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,51.6,32.15,,41.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.24,88,,112.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.14,33.11,,42.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.6,144.45,
COCAINE 4% SOLN 4ML,299003,CDM,250,RC,,,Outpatient,,,160.75,96.45,,136.64,85,,109.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.68,32.15,,41.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.65,80.03,,102.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.68,90,,115.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.68,32.15,,41.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.68,32.15,,41.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.46,88,,113.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.22,33.11,,42.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.68,144.68,
DEVICE ELECTROSURGICAL TISSUE 10' CORD,491035,CDM,270,RC,,,Outpatient,,,160.75,96.45,,136.64,85,,109.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.68,32.15,,41.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.65,80.03,,102.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.68,90,,115.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.68,32.15,,41.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.68,32.15,,41.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.46,88,,113.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.22,33.11,,42.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.68,144.68,
"OPIATES, QT  (MAYO)",1882211,CDM,300,RC,80364,HCPCS,Outpatient,,,160.75,96.45,,136.64,85,,109.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,128.65,80.03,,102.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.68,90,,115.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,24.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,141.46,88,,113.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.47,144.68,
"FLOW CYTO, 9-15 ADDL MARKERS INTERP",2188183,CDM,310,RC,88188,HCPCS,Outpatient,,,160.75,96.45,,136.64,85,,109.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,128.65,80.03,,102.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.68,90,,115.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,74.6,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,141.46,88,,113.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.84,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,74.6,144.68,
PYRIDOXAL 5-PHOSPHATE (PLP)  MAYO),1884207,CDM,300,RC,84207,HCPCS,Outpatient,,,161.5,96.9,,137.28,85,,109.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,129.25,80.03,,103.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,28.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,145.35,90,,116.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,28.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,35.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,142.12,88,,113.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,35.33,145.35,
"ADNEXAL EXAM,LIMITED",1490010,CDM,450,RC,,,Outpatient,,,161.75,97.05,,137.49,85,,109.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52,32.15,,41.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.45,80.03,,103.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.58,90,,116.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52,32.15,,41.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52,32.15,,41.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.34,88,,113.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.56,33.11,,42.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52,145.58,
"ADNEXAL,EXAM,LIMITED",1492002,CDM,450,RC,,,Outpatient,,,161.75,97.05,,137.49,85,,109.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52,32.15,,41.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.45,80.03,,103.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.58,90,,116.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52,32.15,,41.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52,32.15,,41.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.34,88,,113.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.56,33.11,,42.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52,145.58,
THYRO-BINDING INHIB. IMMUNOGLOB (MAYO),1883519,CDM,300,RC,84445,HCPCS,Outpatient,,,162.5,97.5,,138.13,85,,110.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,130.05,80.03,,104.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,51.87,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,146.25,90,,117,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.87,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,143,88,,114.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.65,146.25,
THYROID STIM IMMUNOGLOBUL  (MAYO),1884445,CDM,300,RC,84445,HCPCS,Outpatient,,,162.5,97.5,,138.13,85,,110.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,130.05,80.03,,104.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,51.87,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,146.25,90,,117,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,51.87,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,143,88,,114.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.65,146.25,
BIAXIN (clarithromycin) 250MG/5ML: 100ML,294066,CDM,250,RC,,,Outpatient,,,162.74,97.64,,138.33,85,,110.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.32,32.15,,41.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,80.03,,104.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.47,90,,117.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.32,32.15,,41.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.32,32.15,,41.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.21,88,,114.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.88,33.11,,43.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.32,146.47,
VENOUS STASIS ULCER RX,3930,CDM,420,RC,11040,HCPCS,Outpatient,,,162.8,97.68,,138.38,85,,110.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.34,32.15,,41.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.29,80.03,,104.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.52,90,,117.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.34,32.15,,41.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.34,32.15,,41.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.26,88,,114.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.9,33.11,,43.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.34,146.52,
P/T HEAVY DEBRIDEMENT,3957,CDM,420,RC,97799,HCPCS,Outpatient,,,162.8,97.68,,138.38,85,,110.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.34,32.15,,41.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.29,80.03,,104.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.52,90,,117.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.34,32.15,,41.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.34,32.15,,41.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.26,88,,114.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.9,33.11,,43.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.34,146.52,
NASONEX  (mometasone) 50MCG INH  17G,292083,CDM,250,RC,,,Outpatient,,,163,97.8,,138.55,85,,110.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.4,32.15,,41.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.45,80.03,,104.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.7,90,,117.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.4,32.15,,41.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.4,32.15,,41.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.44,88,,114.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.97,33.11,,43.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.4,146.7,
ZYGOMA <3V,22006,CDM,320,RC,70140,HCPCS,Outpatient,,,163.5,98.1,,138.98,85,,111.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.57,32.15,,42.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.85,80.03,,104.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,147.15,90,,117.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.57,32.15,,42.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,52.57,32.15,,42.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.88,88,,115.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.13,33.11,,43.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.57,147.15,
PAD GROUNDING UNIVERSAL ELECTROSURGICAL,492010,CDM,270,RC,,,Outpatient,,,163.75,98.25,,139.19,85,,111.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.65,32.15,,42.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.05,80.03,,104.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.38,90,,117.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.65,32.15,,42.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.65,32.15,,42.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.1,88,,115.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.22,33.11,,43.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.65,147.38,
"WARFARIN, COUMADIN  (MAYO)",1882495,CDM,300,RC,80299,HCPCS,Outpatient,,,164.25,98.55,,139.61,85,,111.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,131.45,80.03,,105.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,147.83,90,,118.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,144.54,88,,115.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,147.83,
"BK VIRUS, PCR  (MAYO)",1887801,CDM,300,RC,87799,HCPCS,Outpatient,,,164.25,98.55,,139.61,85,,111.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.81,32.15,,42.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.45,80.03,,105.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,43.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,147.83,90,,118.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.81,32.15,,42.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,52.81,32.15,,42.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.54,88,,115.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.38,33.11,,43.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.81,147.83,
Blood test to assist with diagnosis,2188353,CDM,310,RC,88313,HCPCS,Outpatient,,,164.5,98.7,,139.83,85,,111.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,131.65,80.03,,105.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,148.05,90,,118.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,144.76,88,,115.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,148.05,
Blood test to assist with diagnosis,2188354,CDM,310,RC,88313,HCPCS,Outpatient,,,164.5,98.7,,139.83,85,,111.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,131.65,80.03,,105.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,148.05,90,,118.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,144.76,88,,115.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,148.05,
Blood test to assist with diagnosis,2188355,CDM,310,RC,88313,HCPCS,Outpatient,,,164.5,98.7,,139.83,85,,111.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,131.65,80.03,,105.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,148.05,90,,118.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,144.76,88,,115.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,148.05,
TUBE TRACH FENESTRATED CUFFED #6,493847,CDM,270,RC,,,Outpatient,,,164.75,98.85,,140.04,85,,112.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.97,32.15,,42.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.85,80.03,,105.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.28,90,,118.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.97,32.15,,42.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.75,,,,Other,Not Separately reimbursable,52.97,32.15,,42.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.98,88,,115.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.55,33.11,,43.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.97,148.28,
MASK RESMED MEDIUM FULL,491602,CDM,270,RC,,,Outpatient,,,165,99,,140.25,85,,112.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.05,80.03,,105.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.5,90,,118.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165,,,,Other,Not Separately reimbursable,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.2,88,,116.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.63,33.11,,43.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.05,148.5,
SHOULDER COMPRESSION WRAP WITH GEL BAGS,4999986,CDM,270,RC,,,Outpatient,,,165,99,,140.25,85,,112.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.05,80.03,,105.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.5,90,,118.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165,,,,Other,Not Separately reimbursable,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.2,88,,116.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.63,33.11,,43.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.05,148.5,
HIP COMPRESSION WRAP WITH GEL BAGS,4999987,CDM,270,RC,,,Outpatient,,,165,99,,140.25,85,,112.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.05,80.03,,105.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.5,90,,118.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165,,,,Other,Not Separately reimbursable,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.2,88,,116.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.63,33.11,,43.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.05,148.5,
FEEDING/SWALLOW EVALUATION,312002,CDM,440,RC,92506,HCPCS,Outpatient,,,165,99,,140.25,85,,112.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.05,80.03,,105.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.5,90,,118.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165,,,,Other,Not Separately reimbursable,53.05,32.15,,42.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.2,88,,116.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.63,33.11,,43.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.05,148.5,
REFUSAL CHARGE,530300,CDM,540,RC,,,Outpatient,,,165.55,99.33,,140.72,85,,112.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.22,32.15,,42.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.49,80.03,,105.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149,90,,119.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.22,32.15,,42.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.55,,,,Other,Not Separately reimbursable,53.22,32.15,,42.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.68,88,,116.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.81,33.11,,43.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.22,149,
PROTHROMBIN G20210A  MUTATION  (MAYO),1885333,CDM,300,RC,81240,HCPCS,Outpatient,,,165.75,99.45,,140.89,85,,112.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132.65,80.03,,106.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,149.18,90,,119.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,145.86,88,,116.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,40,149.18,
HESPAN 6% 500ML,296130,CDM,258,RC,,,Outpatient,,,166.09,99.65,,141.18,85,,112.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.4,32.15,,42.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.92,80.03,,106.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.48,90,,119.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.4,32.15,,42.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,53.4,32.15,,42.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,146.16,88,,116.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.99,33.11,,43.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.4,149.48,
PS/PT AB IGM SERUM  (MAYO),1884877,CDM,300,RC,86148,HCPCS,Outpatient,,,166.18,99.71,,141.25,85,,113,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132.99,80.03,,106.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,149.56,90,,119.65,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.24,88,,116.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.2,149.56,
PS/PT AB IGG SERUM  (MAYO),1884878,CDM,300,RC,86148,HCPCS,Outpatient,,,166.18,99.71,,141.25,85,,113,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,132.99,80.03,,106.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,149.56,90,,119.65,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.24,88,,116.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.2,149.56,
"VON WILLEBRAND FACTOR MULTIMER, P (MAYO)",1885247,CDM,300,RC,85247,HCPCS,Outpatient,,,166.35,99.81,,141.4,85,,113.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,133.13,80.03,,106.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,149.72,90,,119.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.39,88,,117.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.85,149.72,
PAD DUOTHERM 15 X 22,49052,CDM,270,RC,,,Outpatient,,,167,100.2,,141.95,85,,113.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.69,32.15,,42.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,133.65,80.03,,106.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.3,90,,120.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.69,32.15,,42.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,53.69,32.15,,42.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,146.96,88,,117.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.29,33.11,,44.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.69,150.3,
PROTEIN S AG TOTAL (MAYO),1885301,CDM,300,RC,85305,HCPCS,Outpatient,,,167.25,100.35,,142.16,85,,113.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,133.85,80.03,,107.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,150.53,90,,120.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,147.18,88,,117.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.58,150.53,
LENS MORGAN MEDI-FLOW,497512,CDM,270,RC,,,Outpatient,,,167.5,100.5,,142.38,85,,113.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.85,32.15,,43.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.05,80.03,,107.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.75,90,,120.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.85,32.15,,43.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,53.85,32.15,,43.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.4,88,,117.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.46,33.11,,44.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.85,150.75,
OSMOTIC FRAGILITY  (MAYO),1882051,CDM,300,RC,85557,HCPCS,Outpatient,,,167.5,100.5,,142.38,85,,113.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,134.05,80.03,,107.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,150.75,90,,120.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,147.4,88,,117.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.79,150.75,
TRYPAN VISION BLUE 0.06% 2.25ML,293174,CDM,250,RC,,,Outpatient,,,167.52,100.51,,142.39,85,,113.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.86,32.15,,43.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.07,80.03,,107.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.77,90,,120.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.86,32.15,,43.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,53.86,32.15,,43.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.42,88,,117.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.47,33.11,,44.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.86,150.77,
ZOVIRAX (acyclovir): 500MG /100ML PB,293258,CDM,250,RC,,,Outpatient,,,167.64,100.58,,142.49,85,,113.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.9,32.15,,43.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.16,80.03,,107.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.88,90,,120.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.9,32.15,,43.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,53.9,32.15,,43.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.52,88,,118.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.51,33.11,,44.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.9,150.88,
DEXAMETHASONE  (MAYO),1880295,CDM,300,RC,82542,HCPCS,Outpatient,,,167.75,100.65,,142.59,85,,114.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,134.25,80.03,,107.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,150.98,90,,120.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,147.62,88,,118.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,150.98,
BAL IN OIL : 3ML AMPULE,293035,CDM,636,RC,J0470,HCPCS,Outpatient,,,168,100.8,,142.8,85,,114.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.01,32.15,,43.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.45,80.03,,107.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,61,102,,,fee schedule,Pays at 102% of CMS APC rate,151.2,90,,120.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.01,32.15,,43.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61,100,,,fee schedule,Pays at 100% of CMS APC rate,54.01,32.15,,43.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.84,88,,118.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.62,33.11,,44.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.01,151.2,
HIV-2 AB  (MAYO),1886307,CDM,300,RC,86702,HCPCS,Outpatient,,,168.25,100.95,,143.01,85,,114.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,134.65,80.03,,107.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,151.43,90,,121.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,148.06,88,,118.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.19,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.75,151.43,
Pathology test,2188336,CDM,310,RC,88342,HCPCS,Outpatient,,,168.25,100.95,,143.01,85,,114.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,134.65,80.03,,107.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,151.43,90,,121.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,148.06,88,,118.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,71.58,151.43,
ASSEMBLY GAUGE/SYRINGE 60CC,493437,CDM,270,RC,,,Outpatient,,,168.5,101.1,,143.23,85,,114.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.17,32.15,,43.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.85,80.03,,107.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.65,90,,121.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.17,32.15,,43.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.17,32.15,,43.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.28,88,,118.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.79,33.11,,44.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.17,151.65,
URINE METER 350ML W/ BAG,493946,CDM,270,RC,,,Outpatient,,,168.75,101.25,,143.44,85,,114.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.05,80.03,,108.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.88,90,,121.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.5,88,,118.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.87,33.11,,44.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.25,151.88,
FORK STRAP,499927,CDM,270,RC,L5684,HCPCS,Outpatient,,,168.75,101.25,,143.44,85,,114.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.05,80.03,,108.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.88,90,,121.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.5,88,,118.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.87,33.11,,44.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.25,151.88,
"CYTOTOXIN, C. DIFFICLE AB  (MAYO)",1887230,CDM,300,RC,87230,HCPCS,Outpatient,,,168.75,101.25,,143.44,85,,114.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,135.05,80.03,,108.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,151.88,90,,121.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,148.5,88,,118.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.83,151.88,
SELLA TURCICA,22013,CDM,320,RC,70240,HCPCS,Outpatient,,,168.75,101.25,,143.44,85,,114.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.05,80.03,,108.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,151.88,90,,121.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.5,88,,118.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.87,33.11,,44.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.25,151.88,
WASHED RED CELLS,2086130,CDM,390,RC,P9022,HCPCS,Outpatient,,,168.75,101.25,,143.44,85,,114.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.05,80.03,,108.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,403.69,102,,,fee schedule,Pays at 102% of CMS APC rate,151.88,90,,121.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,403.69,100,,,fee schedule,Pays at 100% of CMS APC rate,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.5,88,,118.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.87,33.11,,44.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.25,151.88,
P/T STRAPPING OF ANKLE,3905,CDM,420,RC,29540,HCPCS,Outpatient,,,168.75,101.25,,143.44,85,,114.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.05,80.03,,108.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,151.88,90,,121.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.5,88,,118.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.87,33.11,,44.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.25,151.88,
DRAPE IOBAN 2,49981,CDM,270,RC,,,Outpatient,,,169.06,101.44,,143.7,85,,114.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.35,32.15,,43.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.3,80.03,,108.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.15,90,,121.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.35,32.15,,43.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.35,32.15,,43.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.77,88,,119.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.98,33.11,,44.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.35,152.15,
DDAVP (desmopressin) : 4MCG/ML INJ,293323,CDM,636,RC,J2597,HCPCS,Outpatient,,,169.32,101.59,,143.92,85,,115.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.44,32.15,,43.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.51,80.03,,108.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.27,102,,,fee schedule,Pays at 102% of CMS APC rate,152.39,90,,121.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.44,32.15,,43.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6.27,100,,,fee schedule,Pays at 100% of CMS APC rate,54.44,32.15,,43.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149,88,,119.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.06,33.11,,44.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.44,152.39,
TRAY AMINOCENTESIS DISPOSABLE,490039,CDM,270,RC,,,Outpatient,,,169.5,101.7,,144.08,85,,115.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.65,80.03,,108.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.55,90,,122.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.16,88,,119.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.12,33.11,,44.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.49,152.55,
ADDITION FROZEN SECTION,2188332,CDM,310,RC,88332,HCPCS,Outpatient,,,169.5,101.7,,144.08,85,,115.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,135.65,80.03,,108.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.55,90,,122.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,37.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.16,88,,119.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.53,152.55,
CHEST OBLIQUE PROJ,22023,CDM,320,RC,71022,HCPCS,Outpatient,,,169.5,101.7,,144.08,85,,115.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.65,80.03,,108.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.55,90,,122.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.16,88,,119.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.12,33.11,,44.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.49,152.55,
Single view,22182,CDM,320,RC,71045,HCPCS,Outpatient,,,169.5,101.7,,144.08,85,,115.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.65,80.03,,108.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,152.55,90,,122.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,54.49,32.15,,43.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.16,88,,119.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.12,33.11,,44.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.49,152.55,
PENCIL CAUTERY ROCKER PTFE STERILE,491030,CDM,270,RC,,,Outpatient,,,169.69,101.81,,144.24,85,,115.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.56,32.15,,43.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.8,80.03,,108.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.72,90,,122.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.56,32.15,,43.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.56,32.15,,43.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.33,88,,119.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.18,33.11,,44.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.56,152.72,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1883536,CDM,300,RC,83516,HCPCS,Outpatient,,,169.75,101.85,,144.29,85,,115.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,135.85,80.03,,108.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,152.78,90,,122.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.38,88,,119.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,152.78,
PROTHROM GENE ANALYSIS  (MAYO),1883897,CDM,300,RC,81240,HCPCS,Outpatient,,,169.75,101.85,,144.29,85,,115.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,135.85,80.03,,108.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,152.78,90,,122.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.38,88,,119.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,40,152.78,
PRESSURE INFUSOR 1000ML,499901,CDM,270,RC,,,Outpatient,,,170,102,,144.5,85,,115.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.66,32.15,,43.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.05,80.03,,108.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153,90,,122.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.66,32.15,,43.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.66,32.15,,43.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.6,88,,119.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.29,33.11,,45.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.66,153,
CORONAVIRUS COVID-19 PCR (DSL),1884881,CDM,300,RC,87635,HCPCS,Outpatient,,,170.69,102.41,,145.09,85,,116.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,136.6,80.03,,109.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,52.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,153.62,90,,122.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.21,88,,120.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.31,153.62,
ASPERGILLAS AG GALACTOMANNAN  (MAYO),1886332,CDM,300,RC,87305,HCPCS,Outpatient,,,170.75,102.45,,145.14,85,,116.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,136.65,80.03,,109.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.21,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,153.68,90,,122.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.21,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.26,88,,120.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,153.68,
SET INFUSER VOLUMN RAPID,496502,CDM,270,RC,,,Outpatient,,,171,102.6,,145.35,85,,116.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.98,32.15,,43.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.85,80.03,,109.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.9,90,,123.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.98,32.15,,43.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.98,32.15,,43.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.48,88,,120.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.62,33.11,,45.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.98,153.9,
WARM & FORM BINDER AND INSERT,31118,CDM,274,RC,L0625,HCPCS,Outpatient,,,171,102.6,,145.35,85,,116.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.98,32.15,,43.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,136.85,80.03,,109.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,53.05,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,153.9,90,,123.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.98,32.15,,43.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.05,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,54.98,32.15,,43.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.48,88,,120.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.62,33.11,,45.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.98,153.9,
"PANCREATIC POLYPEPTIDE, PLASMA  (MAYO)",1883539,CDM,300,RC,83519,HCPCS,Outpatient,,,171.25,102.75,,145.56,85,,116.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,137.05,80.03,,109.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,154.13,90,,123.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.7,88,,120.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,154.13,
MISC DRUG >100,29906,CDM,250,RC,,,Outpatient,,,171.5,102.9,,145.78,85,,116.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.14,32.15,,44.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.25,80.03,,109.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.35,90,,123.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.14,32.15,,44.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.14,32.15,,44.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.92,88,,120.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.78,33.11,,45.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.14,154.35,
KIT ORAL SUCTION VAPREVENT W/CHG 4HR,498008,CDM,270,RC,,,Outpatient,,,171.88,103.13,,146.1,85,,116.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.26,32.15,,44.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.56,80.03,,110.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.69,90,,123.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.26,32.15,,44.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.26,32.15,,44.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.25,88,,121,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.91,33.11,,45.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.26,154.69,
ANTI-SACCHAROMYCES-CEREVISIAE IGA  (MAYO,1886679,CDM,300,RC,83520,HCPCS,Outpatient,,,172,103.2,,146.2,85,,116.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,137.65,80.03,,110.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,154.8,90,,123.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,151.36,88,,121.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,154.8,
CORONAVIRUS COVID-19 PCR (QUEST),1884883,CDM,300,RC,87635,HCPCS,Outpatient,,,172.5,103.5,,146.63,85,,117.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,138.05,80.03,,110.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,52.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,155.25,90,,124.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,151.8,88,,121.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.31,155.25,
"ADNEXAL EXAM, COMPREHENSIVE",1492004,CDM,450,RC,,,Outpatient,,,172.75,103.65,,146.84,85,,117.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.54,32.15,,44.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.25,80.03,,110.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.48,90,,124.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.54,32.15,,44.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.54,32.15,,44.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.02,88,,121.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.2,33.11,,45.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.54,155.48,
CORVERT (IBUTILIDE) 0.1MG/ML INJ: 10ML,293229,CDM,636,RC,J1742,HCPCS,Outpatient,,,173,103.8,,147.05,85,,117.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.62,32.15,,44.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.45,80.03,,110.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,228.51,102,,,fee schedule,Pays at 102% of CMS APC rate,155.7,90,,124.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.62,32.15,,44.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.51,100,,,fee schedule,Pays at 100% of CMS APC rate,55.62,32.15,,44.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.24,88,,121.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.28,33.11,,45.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.62,155.7,
O/T ANKLE/FOOT ORTHOSIS SPLINT,3976,CDM,430,RC,L1940,HCPCS,Outpatient,,,173.35,104.01,,147.35,85,,117.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.73,32.15,,44.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.73,80.03,,110.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.02,90,,124.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.73,32.15,,44.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.73,32.15,,44.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.55,88,,122.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.4,33.11,,45.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.73,156.02,
SMALL UNCOMPLICATED SPECIMEN,2188304,CDM,310,RC,88304,HCPCS,Outpatient,,,173.44,104.06,,147.42,85,,117.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,138.8,80.03,,111.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,156.1,90,,124.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,152.63,88,,122.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.18,156.1,
CAPNOGRAPHY CONT.P,30023,CDM,460,RC,94799,HCPCS,Outpatient,,,173.44,104.06,,147.42,85,,117.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.76,32.15,,44.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.8,80.03,,111.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,156.1,90,,124.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.76,32.15,,44.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,55.76,32.15,,44.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.63,88,,122.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.43,33.11,,45.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.76,156.1,
TUBE FEEDING 10FR ENTERNAL W/STYLET,493809,CDM,270,RC,,,Outpatient,,,173.75,104.25,,147.69,85,,118.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.86,32.15,,44.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.05,80.03,,111.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.38,90,,125.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.86,32.15,,44.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.86,32.15,,44.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.9,88,,122.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.53,33.11,,46.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.86,156.38,
REMOVAL IMPACTED CERUMEN IRRIGAT/LAVAGE,69209,CDM,450,RC,69209,HCPCS,Outpatient,,,173.75,104.25,,147.69,85,,118.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.86,32.15,,44.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.05,80.03,,111.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,156.38,90,,125.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.86,32.15,,44.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,55.86,32.15,,44.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.9,88,,122.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.53,33.11,,46.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.86,156.38,
TUBE FEEDING 8FR ENTERNAL W/STYLET,493811,CDM,270,RC,,,Outpatient,,,174.25,104.55,,148.11,85,,118.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.02,32.15,,44.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.45,80.03,,111.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,90,,125.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.02,32.15,,44.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.02,32.15,,44.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.34,88,,122.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.69,33.11,,46.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.02,156.83,
HAND SPLINT FIT/CONSTRUCTION IV,390,CDM,430,RC,97504,HCPCS,Outpatient,,,174.35,104.61,,148.2,85,,118.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.05,32.15,,44.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.53,80.03,,111.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.92,90,,125.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.05,32.15,,44.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.05,32.15,,44.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.43,88,,122.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.73,33.11,,46.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.05,156.92,
BRACE KNEE 24  TALL UNIVERSAL,491183,CDM,270,RC,,,Outpatient,,,174.5,104.7,,148.33,85,,118.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.1,32.15,,44.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.65,80.03,,111.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.05,90,,125.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.1,32.15,,44.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.1,32.15,,44.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.56,88,,122.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.78,33.11,,46.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.1,157.05,
COLLAGEN TYPE II AB  (MAYO),1883531,CDM,300,RC,83520,HCPCS,Outpatient,,,174.75,104.85,,148.54,85,,118.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,139.85,80.03,,111.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,157.28,90,,125.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,153.78,88,,123.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,157.28,
CHIKUNGUNYA AB IGG  (MAYO),1886760,CDM,300,RC,86790,HCPCS,Outpatient,,,174.75,104.85,,148.54,85,,118.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,139.85,80.03,,111.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,157.28,90,,125.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,153.78,88,,123.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,157.28,
CHIKUNGUNYA AB IGM  (MAYO),1886761,CDM,300,RC,86790,HCPCS,Outpatient,,,174.75,104.85,,148.54,85,,118.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,139.85,80.03,,111.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,157.28,90,,125.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,153.78,88,,123.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.2,157.28,
SYNTHROID (levothyroxine) 100 MCG INJ,293572,CDM,250,RC,,,Outpatient,,,175,105,,148.75,85,,119,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.05,80.03,,112.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,90,,126,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154,88,,123.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.94,33.11,,46.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.26,157.5,
VENOFER (iron sucrose) 100MG/5ML INJ SDV,293532,CDM,636,RC,J1756,HCPCS,Outpatient,,,175,105,,148.75,85,,119,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.05,80.03,,112.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,90,,126,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154,88,,123.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.22,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.21,157.5,
VANCOMYCIN : variable dose (1 gm unit),293533,CDM,636,RC,J3370,HCPCS,Outpatient,,,175,105,,148.75,85,,119,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.05,80.03,,112.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,90,,126,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154,88,,123.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.09,157.5,
PULMMONARY REHAB,459,CDM,948,RC,G0424,HCPCS,Outpatient,,,175,105,,148.75,85,,119,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.05,80.03,,112.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,90,,126,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154,88,,123.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.94,33.11,,46.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.26,157.5,
AMIKIN(amikacin): 1000MG/4ML VIAL,293566,CDM,636,RC,J0278,HCPCS,Outpatient,,,175.2,105.12,,148.92,85,,119.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.21,80.03,,112.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.68,90,,126.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.18,88,,123.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.94,157.68,
BELT TRACTION PELVIC UNIVERSAL,491098,CDM,270,RC,,,Outpatient,,,175.75,105.45,,149.39,85,,119.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.5,32.15,,45.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.65,80.03,,112.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.18,90,,126.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.5,32.15,,45.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.5,32.15,,45.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.66,88,,123.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.19,33.11,,46.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.5,158.18,
DRESSING VAC GRANUFOAM MEDIUM,49683,CDM,270,RC,,,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.58,32.15,,45.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.58,32.15,,45.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.58,32.15,,45.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.27,33.11,,46.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.58,158.4,
MUSCLE ATPASE ACID ALK STAIN (MAYO),2188374,CDM,300,RC,88314,HCPCS,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.62,158.4,
MUSCLE PERIODIC ACID-SCHIFF STAIN (MAYO),2188375,CDM,300,RC,88314,HCPCS,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.62,158.4,
MUSCLE TRICH WATER SOLUBLE STAIN (MAYO),2188376,CDM,300,RC,88314,HCPCS,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.62,158.4,
MUSCLE CONGO RED STAIN (MAYO),2188379,CDM,300,RC,88314,HCPCS,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.62,158.4,
MUSCLE OIL RED O STAIN (MAYO),2188382,CDM,300,RC,88314,HCPCS,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.62,158.4,
MUSCLE TB ATPASE STAIN (MAYO),2188384,CDM,300,RC,88314,HCPCS,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.62,158.4,
MM BREAST SPECIMEN DIAG,2276098,CDM,320,RC,76098,HCPCS,Outpatient,,,176,105.6,,149.6,85,,119.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.58,32.15,,45.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.85,80.03,,112.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.35,102,,,fee schedule,Pays at 102% of CMS APC rate,158.4,90,,126.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.58,32.15,,45.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.35,100,,,fee schedule,Pays at 100% of CMS APC rate,56.58,32.15,,45.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.88,88,,123.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.27,33.11,,46.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.58,158.4,
"RAPAMYCIN, SIROLIMUS (MAYO)",1880298,CDM,300,RC,80195,HCPCS,Outpatient,,,176.65,105.99,,150.15,85,,120.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,141.37,80.03,,113.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,158.99,90,,127.19,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,155.45,88,,124.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.25,158.99,
TUBING INSUFFLATION LAP,493920,CDM,270,RC,,,Outpatient,,,176.88,106.13,,150.35,85,,120.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.87,32.15,,45.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.56,80.03,,113.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.19,90,,127.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.87,32.15,,45.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.87,32.15,,45.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.65,88,,124.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.56,33.11,,46.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.87,159.19,
P/T STRAPPING OF ELBOW OR WRIST,3910,CDM,420,RC,29260,HCPCS,Outpatient,,,177,106.2,,150.45,85,,120.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.65,80.03,,113.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,159.3,90,,127.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.76,88,,124.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.6,33.11,,46.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.91,159.3,
P/T STRAPPING OF HAND OR FINGER,3911,CDM,420,RC,29280,HCPCS,Outpatient,,,177,106.2,,150.45,85,,120.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.65,80.03,,113.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,159.3,90,,127.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.76,88,,124.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.6,33.11,,46.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.91,159.3,
O/T STRAPPING OF ELBOW OR WRIST,3913,CDM,430,RC,29260,HCPCS,Outpatient,,,177,106.2,,150.45,85,,120.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.65,80.03,,113.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,159.3,90,,127.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.76,88,,124.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.6,33.11,,46.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.91,159.3,
O/T STRAPPING OF HAND OR FINGER,3914,CDM,430,RC,29280,HCPCS,Outpatient,,,177,106.2,,150.45,85,,120.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.65,80.03,,113.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,159.3,90,,127.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,56.91,32.15,,45.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.76,88,,124.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.6,33.11,,46.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.91,159.3,
BRACE WRIST FUTURO,49502,CDM,274,RC,L3908,HCPCS,Outpatient,,,177.25,106.35,,150.66,85,,120.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.99,32.15,,45.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,141.85,80.03,,113.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.53,90,,127.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.99,32.15,,45.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.99,32.15,,45.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.98,88,,124.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.69,33.11,,46.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.99,159.53,
"CYSTINURIA PROFILE, 24 HR  (MAYO)",1882129,CDM,300,RC,82136,HCPCS,Outpatient,,,177.25,106.35,,150.66,85,,120.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,141.85,80.03,,113.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,159.53,90,,127.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,155.98,88,,124.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.21,159.53,
Removal of ear wax from one or both ears,69210,CDM,761,RC,69210,HCPCS,Outpatient,,,177.5,106.5,,150.88,85,,120.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.07,32.15,,45.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.05,80.03,,113.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,159.75,90,,127.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.07,32.15,,45.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,57.07,32.15,,45.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.2,88,,124.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.77,33.11,,47.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.07,159.75,
Blood test to assist with diagnosis,2188315,CDM,310,RC,88313,HCPCS,Outpatient,,,177.75,106.65,,151.09,85,,120.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,142.25,80.03,,113.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,159.98,90,,127.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,156.42,88,,125.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,159.98,
LEVEL 1 WITH PROCEDURE,14011,CDM,450,RC,99281,HCPCS,Outpatient,,,178,106.8,,151.3,85,,121.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.45,80.03,,113.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.98,102,,,fee schedule,Pays at 102% of CMS APC rate,160.2,90,,128.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.98,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.64,88,,125.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.45,385,
SUTURE REMOVAL/WOUND RECHECK,14026,CDM,450,RC,99281,HCPCS,Outpatient,,,178,106.8,,151.3,85,,121.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.45,80.03,,113.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.98,102,,,fee schedule,Pays at 102% of CMS APC rate,160.2,90,,128.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.98,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.64,88,,125.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.45,385,
FOOD NUT #1  (MAYO),1886015,CDM,300,RC,86003,HCPCS,Outpatient,,,178.28,106.97,,151.54,85,,121.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,142.68,80.03,,114.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,160.45,90,,128.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,156.89,88,,125.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,160.45,
FOOD NUT #2  (MAYO),1886016,CDM,300,RC,86003,HCPCS,Outpatient,,,178.28,106.97,,151.54,85,,121.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,142.68,80.03,,114.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,160.45,90,,128.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,156.89,88,,125.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,160.45,
ROCEPHIN  (ceftriaxone) 2GM /20ML SW,293333,CDM,636,RC,J0696,HCPCS,Outpatient,,,178.33,107,,151.58,85,,121.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,142.72,80.03,,114.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.5,90,,128.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,156.93,88,,125.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.47,160.5,
KIT OB VACCUM DELIVERY 60MM SMALL,49227,CDM,270,RC,,,Outpatient,,,178.5,107.1,,151.73,85,,121.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.39,32.15,,45.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.85,80.03,,114.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.65,90,,128.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.39,32.15,,45.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,57.39,32.15,,45.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.08,88,,125.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.1,33.11,,47.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.39,160.65,
P/T INTERNAL BIOFEDBACK SENSOR,446,CDM,270,RC,E0746,HCPCS,Outpatient,,,179,107.4,,152.15,85,,121.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.25,80.03,,114.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.1,90,,128.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.52,88,,126.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.27,33.11,,47.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.55,161.1,
Testing for presence of drug,1880110,CDM,300,RC,80307,HCPCS,Outpatient,,,179,107.4,,152.15,85,,121.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,143.25,80.03,,114.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,161.1,90,,128.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,157.52,88,,126.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.16,161.1,
MYCOPLASMA HOMINIS PCR  (MAYO),1882690,CDM,300,RC,82232,HCPCS,Outpatient,,,179.5,107.7,,152.58,85,,122.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,143.65,80.03,,114.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,161.55,90,,129.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,157.96,88,,126.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.35,161.55,
CATH UMBILICAL 3.5FR,49770,CDM,270,RC,,,Outpatient,,,179.75,107.85,,152.79,85,,122.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.85,80.03,,115.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.78,90,,129.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.18,88,,126.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.52,33.11,,47.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.79,161.78,
CATH UMBILICAL 5.0FR,49771,CDM,270,RC,,,Outpatient,,,179.75,107.85,,152.79,85,,122.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.85,80.03,,115.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.78,90,,129.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.18,88,,126.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.52,33.11,,47.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.79,161.78,
ABDOMEN,22079,CDM,320,RC,74018,HCPCS,Outpatient,,,179.75,107.85,,152.79,85,,122.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.85,80.03,,115.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,161.78,90,,129.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.18,88,,126.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.52,33.11,,47.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.79,161.78,
CONSCIOUS SEDATION EA ADDITIONAL 15 MIN,11045,CDM,372,RC,99153,HCPCS,Outpatient,,,179.75,107.85,,152.79,85,,122.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.85,80.03,,115.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.78,90,,129.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,57.79,32.15,,46.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.18,88,,126.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.52,33.11,,47.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.79,161.78,
Test to measure arterial blood gases,30331,CDM,300,RC,82803,HCPCS,Outpatient,,,179.99,107.99,,152.99,85,,122.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,144.05,80.03,,115.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,161.99,90,,129.59,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,158.39,88,,126.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.34,161.99,
CASSETTE ULTRA VERALINK,49691,CDM,270,RC,,,Outpatient,,,180,108,,153,85,,122.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.05,80.03,,115.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162,90,,129.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.4,88,,126.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.6,33.11,,47.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.87,162,
VENTILATOR TRANSPORT PER HOUR,30060,CDM,410,RC,94002,HCPCS,Outpatient,,,180,108,,153,85,,122.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.05,80.03,,115.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,533.72,102,,,fee schedule,Pays at 102% of CMS APC rate,162,90,,129.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,533.72,100,,,fee schedule,Pays at 100% of CMS APC rate,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.4,88,,126.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.6,33.11,,47.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.87,162,
PEPCID (famotidine) 40MG/5ML SUSP: 50ML,292308,CDM,250,RC,,,Outpatient,,,180.51,108.31,,153.43,85,,122.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.03,32.15,,46.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.46,80.03,,115.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.46,90,,129.97,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.03,32.15,,46.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.03,32.15,,46.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.85,88,,127.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.77,33.11,,47.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.03,162.46,
TOBRADEX OPTH OINT 3.5G,297706,CDM,250,RC,,,Outpatient,,,180.6,108.36,,153.51,85,,122.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.06,32.15,,46.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.53,80.03,,115.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.54,90,,130.03,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.06,32.15,,46.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.06,32.15,,46.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.93,88,,127.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.8,33.11,,47.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.06,162.54,
DIFLUCAN (fluconazole) SUSP 40MG/ML 35ML,292333,CDM,250,RC,,,Outpatient,,,180.75,108.45,,153.64,85,,122.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.11,32.15,,46.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.65,80.03,,115.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.68,90,,130.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.11,32.15,,46.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.11,32.15,,46.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.06,88,,127.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.85,33.11,,47.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.11,162.68,
DRESSING SIMPLACE MEDIUM VAC KIT,49686,CDM,270,RC,,,Outpatient,,,181.25,108.75,,154.06,85,,123.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.27,32.15,,46.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.05,80.03,,116.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.13,90,,130.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.27,32.15,,46.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.27,32.15,,46.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.5,88,,127.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.01,33.11,,48.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.27,163.13,
IRRIGATION OF VENUOU ACCESS (HEP FLUSH),96523,CDM,761,RC,96523,HCPCS,Outpatient,,,181.25,108.75,,154.06,85,,123.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.27,32.15,,46.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.05,80.03,,116.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,163.13,90,,130.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.27,32.15,,46.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,58.27,32.15,,46.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.5,88,,127.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.01,33.11,,48.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.27,163.13,
NEEDLE BIOPSY 14G X 11CM ACHIEVE COAXIAL,491435,CDM,270,RC,,,Outpatient,,,181.75,109.05,,154.49,85,,123.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.45,80.03,,116.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.58,90,,130.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.94,88,,127.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.18,33.11,,48.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.43,163.58,
KIT CLOSED WOUND SUCTION MED-LRG 3/16,491478,CDM,270,RC,,,Outpatient,,,181.75,109.05,,154.49,85,,123.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.45,80.03,,116.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.58,90,,130.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.94,88,,127.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.18,33.11,,48.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.43,163.58,
SET VISIFLOW IRRIGATION STARTER 1 3/4,493213,CDM,270,RC,,,Outpatient,,,181.75,109.05,,154.49,85,,123.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.45,80.03,,116.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.58,90,,130.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.43,32.15,,46.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.94,88,,127.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.18,33.11,,48.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.43,163.58,
"ROHIPNOL, FLUNITRAZEPAM   (MAYO)",1880111,CDM,300,RC,80154,HCPCS,Outpatient,,,182.75,109.65,,155.34,85,,124.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.75,32.15,,47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,146.25,80.03,,117,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.48,90,,131.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.75,32.15,,47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.75,32.15,,47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.82,88,,128.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.51,33.11,,48.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.75,164.48,
ARIXTRA (FONDAPARINUX)  (MAYO),1885130,CDM,300,RC,85130,HCPCS,Outpatient,,,183,109.8,,155.55,85,,124.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.45,80.03,,117.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,164.7,90,,131.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.96,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,161.04,88,,128.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.96,164.7,
ANTI-PANCREATIC ISLET CELL  (MAYO),1886249,CDM,300,RC,86255,HCPCS,Outpatient,,,183,109.8,,155.55,85,,124.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.45,80.03,,117.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,164.7,90,,131.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,161.04,88,,128.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,164.7,
SET INTRODUCER 9FR SUBCLAVIAN,4999006,CDM,270,RC,,,Outpatient,,,183.25,109.95,,155.76,85,,124.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.91,32.15,,47.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,146.65,80.03,,117.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.93,90,,131.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.91,32.15,,47.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,58.91,32.15,,47.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,161.26,88,,129.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.67,33.11,,48.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.91,164.93,
CROSSMATCH,2086074,CDM,300,RC,86904,HCPCS,Outpatient,,,183.27,109.96,,155.78,85,,124.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.67,80.03,,117.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,164.94,90,,131.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,11.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,161.28,88,,129.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.31,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.95,164.94,
HEPATAMINE (8% AMINO ACID) 500ML,296389,CDM,258,RC,,,Outpatient,,,183.86,110.32,,156.28,85,,125.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.11,32.15,,47.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.14,80.03,,117.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.47,90,,132.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.11,32.15,,47.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.11,32.15,,47.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,161.8,88,,129.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.88,33.11,,48.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.11,165.47,
SLING AND SWATHE,491240,CDM,270,RC,,,Outpatient,,,184,110.4,,156.4,85,,125.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.16,32.15,,47.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.26,80.03,,117.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.6,90,,132.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.16,32.15,,47.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.16,32.15,,47.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,161.92,88,,129.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.92,33.11,,48.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.16,165.6,
COAG FACTOR VIII ASSAY P (MAYO),1885315,CDM,300,RC,85240,HCPCS,Outpatient,,,184.25,110.55,,156.61,85,,125.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,147.46,80.03,,117.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,165.83,90,,132.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,162.14,88,,129.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.52,165.83,
CRUTCH ADULT 5'2  - 5'10,491199,CDM,270,RC,,,Outpatient,,,185,111,,157.25,85,,125.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.48,32.15,,47.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.06,80.03,,118.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.5,90,,133.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.48,32.15,,47.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.48,32.15,,47.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.8,88,,130.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.25,33.11,,49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.48,166.5,
P/T ADULT NEURO EVALUATION,311102,CDM,420,RC,97750,HCPCS,Outpatient,,,185,111,,157.25,85,,125.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.48,32.15,,47.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.06,80.03,,118.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,166.5,90,,133.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.48,32.15,,47.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,59.48,32.15,,47.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.8,88,,130.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.25,33.11,,49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.48,166.5,
HEALON 0.4ML OPTH,296075,CDM,250,RC,,,Outpatient,,,185.92,111.55,,158.03,85,,126.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.77,32.15,,47.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.79,80.03,,119.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.33,90,,133.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.77,32.15,,47.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.77,32.15,,47.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.61,88,,130.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.56,33.11,,49.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.77,167.33,
BRACE STIRRUP ANKLE,491227,CDM,270,RC,,,Outpatient,,,185.94,111.56,,158.05,85,,126.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.78,32.15,,47.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.81,80.03,,119.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.35,90,,133.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.78,32.15,,47.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.78,32.15,,47.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.63,88,,130.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.56,33.11,,49.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.78,167.35,
Testing for presence of drug,1880104,CDM,300,RC,80307,HCPCS,Outpatient,,,186.25,111.75,,158.31,85,,126.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.06,80.03,,119.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,167.63,90,,134.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,163.9,88,,131.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.16,167.63,
Testing for presence of drug,1882144,CDM,300,RC,80307,HCPCS,Outpatient,,,186.25,111.75,,158.31,85,,126.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.06,80.03,,119.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,167.63,90,,134.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,163.9,88,,131.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.16,167.63,
"KAOLIN CLOTTING TIME, PTT-LA  (MAYO)",1885347,CDM,300,RC,85347,HCPCS,Outpatient,,,186.25,111.75,,158.31,85,,126.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.06,80.03,,119.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.36,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,167.63,90,,134.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.36,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,163.9,88,,131.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.36,167.63,
"PARVOVIRUS, PCR, IGM  (MAYO)",1887800,CDM,300,RC,87798,HCPCS,Outpatient,,,186.25,111.75,,158.31,85,,126.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.06,80.03,,119.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,167.63,90,,134.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,163.9,88,,131.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,167.63,
TISSUE CULTURE NEOPLASTIC DISORDERS,2188284,CDM,300,RC,88237,HCPCS,Outpatient,,,187,112.2,,158.95,85,,127.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.66,80.03,,119.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,146.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,168.3,90,,134.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,164.56,88,,131.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,111.02,168.3,
SEREVENT DISKUS 50MCG #60 BLISTER,292057,CDM,636,RC,J3535,HCPCS,Outpatient,,,187,112.2,,158.95,85,,127.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.12,32.15,,48.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.66,80.03,,119.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,90,,134.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.12,32.15,,48.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,60.12,32.15,,48.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.56,88,,131.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.92,33.11,,49.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.12,168.3,
INJECTION FEE SC IM,11012,CDM,260,RC,96372,HCPCS,Outpatient,,,187.21,112.33,,159.13,85,,127.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.19,32.15,,48.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.82,80.03,,119.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.68,102,,,fee schedule,Pays at 102% of CMS APC rate,168.49,90,,134.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.19,32.15,,48.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.68,100,,,fee schedule,Pays at 100% of CMS APC rate,60.19,32.15,,48.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.74,88,,131.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.99,33.11,,49.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.19,168.49,
HYDROXYPREGNENOLONE 17  (MAYO),1884143,CDM,300,RC,84143,HCPCS,Outpatient,,,187.25,112.35,,159.16,85,,127.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.86,80.03,,119.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.26,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,168.53,90,,134.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.26,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.7,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,164.78,88,,131.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.7,168.53,
TISSUE CULTURE BONE MARROW   (CSI),2188370,CDM,310,RC,88237,HCPCS,Outpatient,,,187.25,112.35,,159.16,85,,127.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,149.86,80.03,,119.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,146.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,168.53,90,,134.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,146.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,111.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,164.78,88,,131.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,111.02,168.53,
P/T STRAPPING OF KNEE,3904,CDM,420,RC,29530,HCPCS,Outpatient,,,187.25,112.35,,159.16,85,,127.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.2,32.15,,48.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.86,80.03,,119.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,168.53,90,,134.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.2,32.15,,48.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,60.2,32.15,,48.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.78,88,,131.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62,33.11,,49.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.2,168.53,
P/T STRAPPING OF LOW BACK,3908,CDM,420,RC,29799,HCPCS,Outpatient,,,187.25,112.35,,159.16,85,,127.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.2,32.15,,48.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.86,80.03,,119.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,168.53,90,,134.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.2,32.15,,48.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,60.2,32.15,,48.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.78,88,,131.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62,33.11,,49.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.2,168.53,
MONOFOCAL LENS,110026,CDM,276,RC,V2632,HCPCS,Outpatient,,,187.5,112.5,,159.38,85,,127.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.28,32.15,,48.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.06,80.03,,120.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,90,,135,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.28,32.15,,48.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,60.28,32.15,,48.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165,88,,132,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.08,33.11,,49.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.28,168.75,
CORONAVIRUS COVID-19 PCR (SCH),1884896,CDM,300,RC,87635,HCPCS,Outpatient,,,187.5,112.5,,159.38,85,,127.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.06,80.03,,120.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,52.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,168.75,90,,135,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,51.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165,88,,132,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,51.31,168.75,
COVID ANTIGEN,1886716,CDM,300,RC,87426,HCPCS,Outpatient,,,187.5,112.5,,159.38,85,,127.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.06,80.03,,120.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,36.03,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,168.75,90,,135,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.03,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,36.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165,88,,132,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.27,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.18,168.75,
"FLOW CYTO, 16 OR MORE MARKERS  INTERP",2188372,CDM,300,RC,88189,HCPCS,Outpatient,,,187.5,112.5,,159.38,85,,127.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.06,80.03,,120.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,90,,135,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,98.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165,88,,132,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,98.26,168.75,
URETHROGRAM RETRO OPERATIVE,22101,CDM,320,RC,74450,HCPCS,Outpatient,,,187.5,112.5,,159.38,85,,127.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.28,32.15,,48.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.06,80.03,,120.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,168.75,90,,135,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.28,32.15,,48.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,60.28,32.15,,48.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165,88,,132,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.08,33.11,,49.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.28,168.75,
SUBSEQUENT HAND HELD NEBULIZER,30266,CDM,410,RC,94640,HCPCS,Outpatient,,,187.88,112.73,,159.7,85,,127.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.4,32.15,,48.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.36,80.03,,120.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,169.09,90,,135.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.4,32.15,,48.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,60.4,32.15,,48.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.33,88,,132.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.21,33.11,,49.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.4,169.09,
SUCTION INPATIENT,30325,CDM,410,RC,31720,HCPCS,Outpatient,,,187.88,112.73,,159.7,85,,127.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.4,32.15,,48.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.36,80.03,,120.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,169.09,90,,135.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.4,32.15,,48.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,60.4,32.15,,48.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.33,88,,132.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.21,33.11,,49.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.4,169.09,
CANDIDA SKIN TEST,293254,CDM,250,RC,,,Outpatient,,,188,112.8,,159.8,85,,127.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.44,32.15,,48.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.46,80.03,,120.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.2,90,,135.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.44,32.15,,48.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,60.44,32.15,,48.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.44,88,,132.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.25,33.11,,49.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.44,169.2,
VISIT - NEW PATIENT - LEVEL 1,99201,CDM,510,RC,99201,HCPCS,Outpatient,,,188,112.8,,159.8,85,,127.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.44,32.15,,48.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.46,80.03,,120.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.2,90,,135.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.44,32.15,,48.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,60.44,32.15,,48.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.44,88,,132.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.25,33.11,,49.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.44,169.2,
"FUNGITELL, SERUM  (MAYO)",1884699,CDM,300,RC,87449,HCPCS,Outpatient,,,188.25,112.95,,160.01,85,,128.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.66,80.03,,120.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.21,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,169.43,90,,135.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.21,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165.66,88,,132.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,169.43,
"TOXOCARA CANIS AB IGG, SERUM  (MAYO)",1886322,CDM,300,RC,86682,HCPCS,Outpatient,,,188.25,112.95,,160.01,85,,128.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.66,80.03,,120.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.27,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,169.43,90,,135.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.27,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165.66,88,,132.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.84,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.35,169.43,
CLIP PLACEMENT,2219201,CDM,621,RC,19101,HCPCS,Outpatient,,,188.5,113.1,,160.23,85,,128.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.6,32.15,,48.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.86,80.03,,120.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3295.83,102,,,fee schedule,Pays at 102% of CMS APC rate,169.65,90,,135.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.6,32.15,,48.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3295.83,100,,,fee schedule,Pays at 100% of CMS APC rate,60.6,32.15,,48.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.88,88,,132.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.41,33.11,,49.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.6,169.65,
IV THERAPY ADDITIONAL NEW DRUG,1496367,CDM,260,RC,96367,HCPCS,Outpatient,,,188.75,113.25,,160.44,85,,128.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.68,32.15,,48.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.06,80.03,,120.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,64.66,102,,,fee schedule,Pays at 102% of CMS APC rate,169.88,90,,135.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.68,32.15,,48.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.66,100,,,fee schedule,Pays at 100% of CMS APC rate,60.68,32.15,,48.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,166.1,88,,132.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.5,33.11,,50,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.68,169.88,
Test of tissues for diagnosis of abnormalities,1888305,CDM,310,RC,88305,HCPCS,Outpatient,,,189.25,113.55,,160.86,85,,128.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,151.46,80.03,,121.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,170.33,90,,136.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,166.54,88,,133.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,65.88,170.33,
Test of tissues for diagnosis of abnormalities,2188305,CDM,310,RC,88305,HCPCS,Outpatient,,,189.25,113.55,,160.86,85,,128.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,151.46,80.03,,121.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,170.33,90,,136.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,166.54,88,,133.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,65.88,170.33,
CARDIO/PULM RESUSCITATION,30280,CDM,480,RC,92950,HCPCS,Outpatient,,,189.25,113.55,,160.86,85,,128.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.84,32.15,,48.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.46,80.03,,121.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.48,102,,,fee schedule,Pays at 102% of CMS APC rate,170.33,90,,136.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.84,32.15,,48.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.48,100,,,fee schedule,Pays at 100% of CMS APC rate,60.84,32.15,,48.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,166.54,88,,133.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.66,33.11,,50.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.84,170.33,
ADVAIR 45/21 HFA 12GM,292135,CDM,636,RC,J3535,HCPCS,Outpatient,,,189.7,113.82,,161.25,85,,129,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.99,32.15,,48.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.82,80.03,,121.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.73,90,,136.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.99,32.15,,48.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,60.99,32.15,,48.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,166.94,88,,133.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.81,33.11,,50.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.99,170.73,
KIT OB VACCUM DELIVERY 65MM LARGE,49226,CDM,270,RC,,,Outpatient,,,189.75,113.85,,161.29,85,,129.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61,32.15,,48.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.86,80.03,,121.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.78,90,,136.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61,32.15,,48.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61,32.15,,48.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,166.98,88,,133.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.83,33.11,,50.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61,170.78,
YUTOPAR (RITODRINE) 50MG/5ML INJ,293225,CDM,250,RC,,,Outpatient,,,189.78,113.87,,161.31,85,,129.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.01,32.15,,48.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.88,80.03,,121.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.8,90,,136.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.01,32.15,,48.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.01,32.15,,48.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.01,88,,133.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.84,33.11,,50.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.01,170.8,
FACTOR V INHIBITOR SCREEN  (MAYO),1884874,CDM,300,RC,85335,HCPCS,Outpatient,,,189.95,113.97,,161.46,85,,129.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,152.02,80.03,,121.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,170.96,90,,136.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,167.16,88,,133.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,170.96,
DO NOT USE,31108,CDM,270,RC,,,Outpatient,,,190,114,,161.5,85,,129.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.09,32.15,,48.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.06,80.03,,121.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,90,,136.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.09,32.15,,48.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.09,32.15,,48.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.2,88,,133.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.91,33.11,,50.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.09,171,
DO NOT USE,31111,CDM,270,RC,97122,HCPCS,Outpatient,,,190,114,,161.5,85,,129.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.09,32.15,,48.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.06,80.03,,121.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,90,,136.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.09,32.15,,48.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.09,32.15,,48.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.2,88,,133.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.91,33.11,,50.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.09,171,
"EOSINOPHILS, U EOSU1  (MAYO)",1885012,CDM,300,RC,85999,HCPCS,Outpatient,,,190.25,114.15,,161.71,85,,129.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.17,32.15,,48.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.26,80.03,,121.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.23,90,,136.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.17,32.15,,48.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.17,32.15,,48.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.42,88,,133.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.99,33.11,,50.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.17,171.23,
FLOVENT HFA 44MCG INHALER,292029,CDM,250,RC,,,Outpatient,,,190.8,114.48,,162.18,85,,129.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.34,32.15,,49.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.7,80.03,,122.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.72,90,,137.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.34,32.15,,49.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.34,32.15,,49.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.9,88,,134.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.17,33.11,,50.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.34,171.72,
KIT HANA PROFX PATIENT CARE,4999056,CDM,270,RC,,,Outpatient,,,191.25,114.75,,162.56,85,,130.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.49,32.15,,49.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.06,80.03,,122.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.13,90,,137.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.49,32.15,,49.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.49,32.15,,49.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.3,88,,134.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.32,33.11,,50.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.49,172.13,
PHOSPHATIDYLETHANOL PETH FFPET (MAYO),1883664,CDM,300,RC,80321,HCPCS,Outpatient,,,191.25,114.75,,162.56,85,,130.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,153.06,80.03,,122.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.13,90,,137.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,168.3,88,,134.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.59,172.13,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,188406,CDM,300,RC,87205,HCPCS,Outpatient,,,191.5,114.9,,162.78,85,,130.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,153.26,80.03,,122.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,172.35,90,,137.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2.95,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,168.52,88,,134.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.95,172.35,
P/T NPWT <50cm2,3980,CDM,420,RC,97605,HCPCS,Outpatient,,,191.5,114.9,,162.78,85,,130.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.57,32.15,,49.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.26,80.03,,122.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,172.35,90,,137.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.57,32.15,,49.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,61.57,32.15,,49.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.52,88,,134.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.41,33.11,,50.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.57,172.35,
WRENCH KIT STERILE,4999940,CDM,270,RC,,,Outpatient,,,191.75,115.05,,162.99,85,,130.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.65,32.15,,49.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.46,80.03,,122.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.58,90,,138.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.65,32.15,,49.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.65,32.15,,49.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.74,88,,134.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.49,33.11,,50.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.65,172.58,
MONITOR SLEEP APNEA 24HR,49093,CDM,270,RC,,,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
MONITOR CARDIAC APNEA (DAILEY) (NEWBORN),490005,CDM,270,RC,,,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
TRAY PERITONEAL LAVAGE,497401,CDM,270,RC,,,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
O/T CUSTOM THUMB SPICA W/FOREARM SUPPORT,3941,CDM,274,RC,L3907,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
"RAST, SHELLFISH & FISH  (MAYO)",1885997,CDM,300,RC,86003,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.32,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.32,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.57,173.25,
MYCOBACTERIA ID PROBE  (MAYO),1887155,CDM,300,RC,87150,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
AUTOLOGOUS DONATION,2086127,CDM,300,RC,86890,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
"2 views, front and back",22002,CDM,320,RC,71046,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
STERNOCLAVICULAR JOINTS 3V,22030,CDM,320,RC,71130,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
Radiologic examination of the foot with 3 or more views,22094,CDM,320,RC,73630,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
Radiologic examination of the knee with 3 views,22105,CDM,320,RC,73562,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
Radiologic examination of the ankle with 3 views,22116,CDM,320,RC,73610,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
X-ray of the hand with 3 or more views,22152,CDM,320,RC,73130,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
Radiologic examination of the knee with 3 views,22291,CDM,320,RC,73562,HCPCS,Outpatient,,,192.5,115.5,,163.63,85,,130.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.06,80.03,,123.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,173.25,90,,138.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,61.89,32.15,,49.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.4,88,,135.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.74,33.11,,50.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.89,173.25,
AZACTAM (aztreonam) : 2GM VIAL,293348,CDM,250,RC,S0073,HCPCS,Outpatient,,,192.72,115.63,,163.81,85,,131.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.96,32.15,,49.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.23,80.03,,123.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.45,90,,138.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.96,32.15,,49.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.96,32.15,,49.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.59,88,,135.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.81,33.11,,51.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.96,173.45,
TUBE FEEDING 12FR ENTERNAL W/STYLET,493810,CDM,270,RC,,,Outpatient,,,192.75,115.65,,163.84,85,,131.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.97,32.15,,49.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.26,80.03,,123.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.48,90,,138.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.97,32.15,,49.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,61.97,32.15,,49.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.62,88,,135.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.82,33.11,,51.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.97,173.48,
NEUTROPHIL OXIDATIVE BURST  (MAYO),1888184,CDM,300,RC,82657,HCPCS,Outpatient,,,192.75,115.65,,163.84,85,,131.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.26,80.03,,123.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,173.48,90,,138.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,169.62,88,,135.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,173.48,
AMIKIN (amikacin) 500MG/NS 100ML PB,293006,CDM,636,RC,J0278,HCPCS,Outpatient,,,193,115.8,,164.05,85,,131.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,154.46,80.03,,123.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.7,90,,138.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,193,,,,Other,Not Separately reimbursable,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,169.84,88,,135.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.94,173.7,
BINDER ABDOMINAL 10  UNIVERSAL  27-48,491151,CDM,270,RC,,,Outpatient,,,193.25,115.95,,164.26,85,,131.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.13,32.15,,49.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.66,80.03,,123.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.93,90,,139.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.13,32.15,,49.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.25,,,,Other,Not Separately reimbursable,62.13,32.15,,49.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.06,88,,136.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.99,33.11,,51.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.13,173.93,
ADVNCED CARE PLAN 30 MIN,8799497,CDM,940,RC,99497,HCPCS,Outpatient,,,193.25,115.95,,164.26,85,,131.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.13,32.15,,49.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.66,80.03,,123.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,72.7,102,,,fee schedule,Pays at 102% of CMS APC rate,173.93,90,,139.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.13,32.15,,49.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.7,100,,,fee schedule,Pays at 100% of CMS APC rate,62.13,32.15,,49.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.06,88,,136.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.99,33.11,,51.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.13,173.93,
RHINOCORT AQUA (budesonide) 32MCG,292250,CDM,250,RC,,,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.5,,,,Other,Not Separately reimbursable,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
Echo with doppler,3009,CDM,480,RC,93320,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.5,,,,Other,Not Separately reimbursable,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
DOPPLER ECHO COLOR FLOW,3010,CDM,480,RC,93325,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.5,,,,Other,Not Separately reimbursable,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
Echo with doppler,4016,CDM,480,RC,93320,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.5,,,,Other,Not Separately reimbursable,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
DOPPLER ECHO COLOR FLOW,4017,CDM,480,RC,93325,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.5,,,,Other,Not Separately reimbursable,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
Echo with doppler,15009,CDM,480,RC,93320,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.5,,,,Other,Not Separately reimbursable,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
DOPPLER ECHO COLOR FLOW STEP DOWN/ICU,15010,CDM,480,RC,93325,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.5,,,,Other,Not Separately reimbursable,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
EKG,28001,CDM,730,RC,93005,HCPCS,Outpatient,,,193.73,116.24,,164.67,85,,131.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.28,32.15,,49.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.04,80.03,,124.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,174.36,90,,139.49,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.28,32.15,,49.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,62.28,32.15,,49.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.48,88,,136.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.14,33.11,,51.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.28,174.36,
DRESSING DUODERM SIGNAL 4 X 4,493266,CDM,270,RC,,,Outpatient,,,194,116.4,,164.9,85,,131.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.26,80.03,,124.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.6,90,,139.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194,,,,Other,Not Separately reimbursable,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.72,88,,136.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.23,33.11,,51.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.37,174.6,
TUBE ENDOTRACH CUFFED LASER-FLEX 4.5MM,493805,CDM,270,RC,,,Outpatient,,,194,116.4,,164.9,85,,131.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.26,80.03,,124.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.6,90,,139.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194,,,,Other,Not Separately reimbursable,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.72,88,,136.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.23,33.11,,51.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.37,174.6,
TUBE ENDOTRACH CUFFED LASER-FLEX 5.0MM,493806,CDM,270,RC,,,Outpatient,,,194,116.4,,164.9,85,,131.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.26,80.03,,124.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.6,90,,139.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194,,,,Other,Not Separately reimbursable,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.72,88,,136.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.23,33.11,,51.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.37,174.6,
"PYRUVATE KINASE, RBC  (MAYO)",1882963,CDM,300,RC,84220,HCPCS,Outpatient,,,194,116.4,,164.9,85,,131.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,155.26,80.03,,124.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,174.6,90,,139.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,170.72,88,,136.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.22,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.86,174.6,
CYTOPATHOLOGY FLUID,8810426,CDM,310,RC,88104,HCPCS,Outpatient,,,194,116.4,,164.9,85,,131.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,155.26,80.03,,124.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,174.6,90,,139.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,42.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,170.72,88,,136.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,42.68,174.6,
SALIVARY GLAND CALCULUS,22018,CDM,320,RC,70380,HCPCS,Outpatient,,,194,116.4,,164.9,85,,131.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.26,80.03,,124.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,174.6,90,,139.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.72,88,,136.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.23,33.11,,51.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.37,174.6,
O/T NEOPRENE ELBOW SLEEVE,3952,CDM,430,RC,L3701,HCPCS,Outpatient,,,194,116.4,,164.9,85,,131.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.26,80.03,,124.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.6,90,,139.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194,,,,Other,Not Separately reimbursable,62.37,32.15,,49.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.72,88,,136.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.23,33.11,,51.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.37,174.6,
VISCOAT (CHONDROIT.HYALURONATE) 0.5ML,297737,CDM,250,RC,,,Outpatient,,,194.16,116.5,,165.04,85,,132.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.42,32.15,,49.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.39,80.03,,124.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.74,90,,139.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.42,32.15,,49.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.16,,,,Other,Not Separately reimbursable,62.42,32.15,,49.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.86,88,,136.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.29,33.11,,51.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.42,174.74,
PAD THERAPY MUL-T-PAD 13X18,49053,CDM,270,RC,,,Outpatient,,,194.69,116.81,,165.49,85,,132.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.59,32.15,,50.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.81,80.03,,124.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.22,90,,140.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.59,32.15,,50.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.69,,,,Other,Not Separately reimbursable,62.59,32.15,,50.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.33,88,,137.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.46,33.11,,51.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.59,175.22,
WAIST BELT,499926,CDM,270,RC,L5688,HCPCS,Outpatient,,,194.75,116.85,,165.54,85,,132.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.61,32.15,,50.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.86,80.03,,124.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.28,90,,140.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.61,32.15,,50.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,62.61,32.15,,50.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.38,88,,137.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.48,33.11,,51.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.61,175.28,
MM MAMMO SPOT COMPR BILAT,22161,CDM,401,RC,77056,HCPCS,Outpatient,,,194.75,116.85,,165.54,85,,132.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.61,32.15,,50.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,155.86,80.03,,124.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.28,90,,140.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.61,32.15,,50.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.75,,,,Other,Not Separately reimbursable,62.61,32.15,,50.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.38,88,,137.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.48,33.11,,51.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.61,175.28,
DO NOT USE,311101,CDM,420,RC,97750,HCPCS,Outpatient,,,195,117,,165.75,85,,132.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.69,32.15,,50.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.06,80.03,,124.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,175.5,90,,140.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.69,32.15,,50.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,62.69,32.15,,50.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.6,88,,137.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.56,33.11,,51.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.69,175.5,
ROMAZICON (FLUMAZENIL) 0.1MG/ML 5ML VIAL,293114,CDM,250,RC,,,Outpatient,,,195.02,117.01,,165.77,85,,132.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.7,32.15,,50.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.07,80.03,,124.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.52,90,,140.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.7,32.15,,50.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.02,,,,Other,Not Separately reimbursable,62.7,32.15,,50.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.62,88,,137.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.57,33.11,,51.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.7,175.52,
PNEUMONIA PROFILE I  (MAYO),1887002,CDM,300,RC,,,Outpatient,,,195.5,117.3,,166.18,85,,132.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.85,32.15,,50.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.46,80.03,,125.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.95,90,,140.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.85,32.15,,50.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.5,,,,Other,Not Separately reimbursable,62.85,32.15,,50.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.04,88,,137.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.73,33.11,,51.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.85,175.95,
TB SENSITIVITY  (MAYO),1887190,CDM,300,RC,87190,HCPCS,Outpatient,,,195.5,117.3,,166.18,85,,132.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,156.46,80.03,,125.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.45,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,175.95,90,,140.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.45,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.11,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,172.04,88,,137.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.11,175.95,
OPTIVAR (azelastine) OPHTH SOL 6 ML,291099,CDM,250,RC,,,Outpatient,,,195.9,117.54,,166.52,85,,133.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.98,32.15,,50.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.78,80.03,,125.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.31,90,,141.05,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.98,32.15,,50.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.9,,,,Other,Not Separately reimbursable,62.98,32.15,,50.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.39,88,,137.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.86,33.11,,51.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.98,176.31,
CERVICAL COMPLETE,22035,CDM,320,RC,72052,HCPCS,Outpatient,,,195.98,117.59,,166.58,85,,133.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.01,32.15,,50.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.84,80.03,,125.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,176.38,90,,141.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.01,32.15,,50.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,63.01,32.15,,50.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.46,88,,137.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.89,33.11,,51.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.01,176.38,
MORPHINE  (MAYO),1883926,CDM,300,RC,80365,HCPCS,Outpatient,,,196.5,117.9,,167.03,85,,133.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.17,32.15,,50.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.26,80.03,,125.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.85,90,,141.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.17,32.15,,50.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,63.17,32.15,,50.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.92,88,,138.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.06,33.11,,52.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.17,176.85,
NEUTROPHIL SPECIFIC ABS  (MAYO),1883381,CDM,300,RC,86255,HCPCS,Outpatient,,,196.75,118.05,,167.24,85,,133.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,157.46,80.03,,125.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,177.08,90,,141.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,173.14,88,,138.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,177.08,
"P/T EMG BIOFEEDBACK, PELVIC",3350,CDM,420,RC,90911,HCPCS,Outpatient,,,196.75,118.05,,167.24,85,,133.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.46,80.03,,125.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.08,90,,141.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.14,88,,138.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.14,33.11,,52.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.26,177.08,
"P/T EMG BIOFEEDBACK, INITIAL 15 MIN",3190912,CDM,420,RC,90912,HCPCS,Outpatient,,,196.75,118.05,,167.24,85,,133.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.46,80.03,,125.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,42.25,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,177.08,90,,141.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.25,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.14,88,,138.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.14,33.11,,52.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.26,177.08,
"P/T EMG BIOFEEDBACK, EACH ADD 15 MIN",3190913,CDM,420,RC,90913,HCPCS,Outpatient,,,196.75,118.05,,167.24,85,,133.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.46,80.03,,125.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.16,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,177.08,90,,141.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.16,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.14,88,,138.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.14,33.11,,52.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.26,177.08,
"O/T EMG BIOFEEDBACK, INITIAL 15 MIN",5990912,CDM,430,RC,90912,HCPCS,Outpatient,,,196.75,118.05,,167.24,85,,133.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.46,80.03,,125.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,42.25,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,177.08,90,,141.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.25,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.14,88,,138.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.14,33.11,,52.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.26,177.08,
"O/T EMG BIOFEEDBACK, EACH ADD 15 MIN",5990913,CDM,430,RC,90913,HCPCS,Outpatient,,,196.75,118.05,,167.24,85,,133.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.46,80.03,,125.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.16,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,177.08,90,,141.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.16,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,63.26,32.15,,50.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.14,88,,138.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.14,33.11,,52.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.26,177.08,
FRESH FROZEN PLASMA,2086388,CDM,390,RC,86927,HCPCS,Outpatient,,,196.88,118.13,,167.35,85,,133.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.3,32.15,,50.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.56,80.03,,126.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.74,102,,,fee schedule,Pays at 102% of CMS APC rate,177.19,90,,141.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.3,32.15,,50.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.74,100,,,fee schedule,Pays at 100% of CMS APC rate,63.3,32.15,,50.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.25,88,,138.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.19,33.11,,52.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.3,177.19,
TBC IMMUNO WORKUP,2086008,CDM,300,RC,86870,HCPCS,Outpatient,,,197.75,118.65,,168.09,85,,134.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,158.26,80.03,,126.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,177.98,90,,142.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,174.02,88,,139.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.12,177.98,
TRAY THORACENTESIS W/CATHETER,49263,CDM,270,RC,,,Outpatient,,,198.25,118.95,,168.51,85,,134.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.74,32.15,,50.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.66,80.03,,126.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.43,90,,142.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.74,32.15,,50.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,63.74,32.15,,50.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,174.46,88,,139.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.64,33.11,,52.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.74,178.43,
".KAPPA FREE LIGHT CHAIN, SERUM  (MAYO)",1882788,CDM,300,RC,83883,HCPCS,Outpatient,,,198.35,119.01,,168.6,85,,134.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,158.74,80.03,,126.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.87,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,178.52,90,,142.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.87,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,174.55,88,,139.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.1,178.52,
".LAMBDA FREE LIGHT CHAIN, SERUM  (MAYO)",1882789,CDM,300,RC,83883,HCPCS,Outpatient,,,198.35,119.01,,168.6,85,,134.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,158.74,80.03,,126.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.87,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,178.52,90,,142.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.87,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,174.55,88,,139.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.1,178.52,
SET FEEDING 1000ML FLUSH BAG KANGAROO,493828,CDM,270,RC,,,Outpatient,,,198.75,119.25,,168.94,85,,135.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.9,32.15,,51.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.06,80.03,,127.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.88,90,,143.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.9,32.15,,51.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,63.9,32.15,,51.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,174.9,88,,139.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.81,33.11,,52.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.9,178.88,
IMMUNE COMPLEX CD3  (MAYO),1886339,CDM,300,RC,86332,HCPCS,Outpatient,,,198.75,119.25,,168.94,85,,135.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,159.06,80.03,,127.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.85,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,178.88,90,,143.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.85,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,174.9,88,,139.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.65,178.88,
"FUNGUS, UNSPECIFIED, SERUM  (MAYO)",1886671,CDM,300,RC,86671,HCPCS,Outpatient,,,199,119.4,,169.15,85,,135.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,159.26,80.03,,127.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,179.1,90,,143.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,175.12,88,,140.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.88,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.42,179.1,
Outpatient visit of established patient requiring a physician,99212,CDM,510,RC,99212,HCPCS,Outpatient,,,199.06,119.44,,169.2,85,,135.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64,32.15,,51.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.31,80.03,,127.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.15,90,,143.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64,32.15,,51.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,64,32.15,,51.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.17,88,,140.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.91,33.11,,52.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64,179.15,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1886266,CDM,300,RC,83516,HCPCS,Outpatient,,,199.08,119.45,,169.22,85,,135.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,159.32,80.03,,127.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,179.17,90,,143.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,175.19,88,,140.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,179.17,
"Radiologic examination, elbow; 3 or more views",22057,CDM,320,RC,73080,HCPCS,Outpatient,,,199.25,119.55,,169.36,85,,135.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.46,80.03,,127.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,179.33,90,,143.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.34,88,,140.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.97,33.11,,52.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.06,179.33,
Radiologic examination of the knee with 3 views,22072,CDM,320,RC,73562,HCPCS,Outpatient,,,199.25,119.55,,169.36,85,,135.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.46,80.03,,127.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,179.33,90,,143.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.34,88,,140.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.97,33.11,,52.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.06,179.33,
Radiologic examination of the knee with 3 views,22290,CDM,320,RC,73562,HCPCS,Outpatient,,,199.25,119.55,,169.36,85,,135.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.46,80.03,,127.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,179.33,90,,143.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.06,32.15,,51.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.34,88,,140.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.97,33.11,,52.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.06,179.33,
Radiologic examination of the collar bone,22049,CDM,320,RC,73000,HCPCS,Outpatient,,,199.38,119.63,,169.47,85,,135.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.1,32.15,,51.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.56,80.03,,127.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,179.44,90,,143.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.1,32.15,,51.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.1,32.15,,51.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.45,88,,140.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.01,33.11,,52.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.1,179.44,
Radiologic examination of the forearm,22281,CDM,320,RC,73090,HCPCS,Outpatient,,,199.38,119.63,,169.47,85,,135.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.1,32.15,,51.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,159.56,80.03,,127.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,179.44,90,,143.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.1,32.15,,51.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.1,32.15,,51.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.45,88,,140.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.01,33.11,,52.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.1,179.44,
HISTAMINE  PLASMA  (MAYO),1883088,CDM,300,RC,83088,HCPCS,Outpatient,,,199.5,119.7,,169.58,85,,135.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,159.66,80.03,,127.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,179.55,90,,143.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,37.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,175.56,88,,140.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.24,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,37.13,179.55,
Single view,22020,CDM,320,RC,71045,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
"2 views, front and back",22021,CDM,320,RC,71046,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
HUMERUS 2V LT,22055,CDM,320,RC,73060,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Up to 3 views,22059,CDM,320,RC,73110,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
X-ray of the hand with 3 or more views,22061,CDM,320,RC,73130,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
FEMUR 2V LT,22069,CDM,320,RC,73552,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Radiologic examination of the ankle with 3 views,22075,CDM,320,RC,73610,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Radiologic examination of the foot with 3 or more views,22076,CDM,320,RC,73630,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Radiologic examination of the knee with 3 views,22158,CDM,320,RC,73562,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Radiologic examination of the ankle with 3 views,22209,CDM,320,RC,73610,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
FEMUR 2V RT,22277,CDM,320,RC,73552,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
X-ray of the hand with 3 or more views,22283,CDM,320,RC,73130,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Radiologic examination of the knee with 3 views,22287,CDM,320,RC,73562,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Radiologic examination of the finger(s),22377,CDM,320,RC,73140,HCPCS,Outpatient,,,200.63,120.38,,170.54,85,,136.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,160.56,80.03,,128.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,180.57,90,,144.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,64.5,32.15,,51.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.55,88,,141.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.43,33.11,,53.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.5,180.57,
Test of a wound for type of bacterial infection,1889056,CDM,300,RC,87077,HCPCS,Outpatient,,,201.5,120.9,,171.28,85,,137.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,161.26,80.03,,129.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,181.35,90,,145.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,177.32,88,,141.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.16,181.35,
PROGESTERONE 17-OH  (MAYO),1883498,CDM,300,RC,83498,HCPCS,Outpatient,,,201.75,121.05,,171.49,85,,137.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,161.46,80.03,,129.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.71,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,181.58,90,,145.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.71,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,34.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,177.54,88,,142.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,34.16,181.58,
O/T CUSTOM HAND BASED RESTING SPLINT,593906,CDM,270,RC,L3906,HCPCS,Outpatient,,,201.85,121.11,,171.57,85,,137.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.89,32.15,,51.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,161.54,80.03,,129.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.67,90,,145.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.89,32.15,,51.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.89,32.15,,51.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.63,88,,142.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.83,33.11,,53.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.89,181.67,
L-3915-WRIST HAND ORTHOTIC REFAB BRACE,593907,CDM,270,RC,L3915,HCPCS,Outpatient,,,201.85,121.11,,171.57,85,,137.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,64.89,32.15,,51.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,161.54,80.03,,129.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.67,90,,145.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,64.89,32.15,,51.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.89,32.15,,51.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.63,88,,142.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,66.83,33.11,,53.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,64.89,181.67,
Radiologic examination of the heel,22211,CDM,320,RC,73650,HCPCS,Outpatient,,,202.5,121.5,,172.13,85,,137.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.06,80.03,,129.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,182.25,90,,145.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.2,88,,142.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.05,33.11,,53.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.1,182.25,
Radiologic examination of the knee with 1 or 2 views,22236,CDM,320,RC,73560,HCPCS,Outpatient,,,202.5,121.5,,172.13,85,,137.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.06,80.03,,129.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,182.25,90,,145.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.2,88,,142.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.05,33.11,,53.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.1,182.25,
PORT SKULL LTD <4V,22247,CDM,320,RC,70250,HCPCS,Outpatient,,,202.5,121.5,,172.13,85,,137.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.06,80.03,,129.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,182.25,90,,145.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.2,88,,142.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.05,33.11,,53.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.1,182.25,
Radiologic examination of the heel,22354,CDM,320,RC,73650,HCPCS,Outpatient,,,202.5,121.5,,172.13,85,,137.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.06,80.03,,129.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,182.25,90,,145.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.2,88,,142.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.05,33.11,,53.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.1,182.25,
Radiologic examination of the knee with 1 or 2 views,22355,CDM,320,RC,73560,HCPCS,Outpatient,,,202.5,121.5,,172.13,85,,137.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.06,80.03,,129.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,182.25,90,,145.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,65.1,32.15,,52.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.2,88,,142.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.05,33.11,,53.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.1,182.25,
DRAPE INCISE SMALL STERILE,49978,CDM,270,RC,,,Outpatient,,,202.75,121.65,,172.34,85,,137.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.26,80.03,,129.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.48,90,,145.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.42,88,,142.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.13,33.11,,53.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.18,182.48,
SUCTION TUBE 12FR FRAZIER W/VENT CONTROL,491308,CDM,270,RC,,,Outpatient,,,202.75,121.65,,172.34,85,,137.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.26,80.03,,129.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.48,90,,145.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.42,88,,142.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.13,33.11,,53.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.18,182.48,
TRAVATAN Z (travoprost) OPHTH SOL 0.004%,291034,CDM,250,RC,,,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
MAXAIR INHALER,292044,CDM,250,RC,,,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
CLINIMIX 4.25% W/ELECT (C) 2000ML,293584,CDM,258,RC,,,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
CLINIMIX  5% W/ELECT (C) 1000ML,296384,CDM,258,RC,,,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
CLINIMIX  5% W/O ELECT (C) 1000ML,296386,CDM,258,RC,,,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
CLINIMIX 4.25%/10% DEXTROSE W/ELECT (P),296387,CDM,258,RC,,,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
CLINIMIX 4.25%/10% DEXT W/O ELECT (P),296388,CDM,258,RC,,,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
TYGACIL (tigecycline) 50mg VIAL,293495,CDM,636,RC,J3243,HCPCS,Outpatient,,,203,121.8,,172.55,85,,138.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.46,80.03,,129.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.7,90,,146.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.26,32.15,,52.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.64,88,,142.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.21,33.11,,53.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.26,182.7,
S/T EVAL SPEECH GEN DEVICE  ADD 30 MIN,3292608,CDM,440,RC,92608,HCPCS,Outpatient,,,203.25,121.95,,172.76,85,,138.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.34,32.15,,52.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.66,80.03,,130.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,47.12,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,182.93,90,,146.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.34,32.15,,52.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.12,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,65.34,32.15,,52.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.86,88,,143.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.3,33.11,,53.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.34,182.93,
S/T EVAL NON-SPEECH DEVICE ADD 30 MIN,3292618,CDM,440,RC,92618,HCPCS,Outpatient,,,203.25,121.95,,172.76,85,,138.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.34,32.15,,52.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.66,80.03,,130.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,182.93,90,,146.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.34,32.15,,52.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,65.34,32.15,,52.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.86,88,,143.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.3,33.11,,53.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.34,182.93,
IV THERAPY HYDRATION INITIAL HOUR,1496360,CDM,260,RC,96360,HCPCS,Outpatient,,,203.5,122.1,,172.98,85,,138.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.86,80.03,,130.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,183.15,90,,146.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.08,88,,143.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.38,33.11,,53.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.43,183.15,
O/T NEOPRENE THUMB SUPPORT,3946,CDM,430,RC,L3911,HCPCS,Outpatient,,,203.5,122.1,,172.98,85,,138.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.86,80.03,,130.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.15,90,,146.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.08,88,,143.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.38,33.11,,53.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.43,183.15,
O/T WRIST DAY/TIMER,3953,CDM,430,RC,L3908,HCPCS,Outpatient,,,203.5,122.1,,172.98,85,,138.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.86,80.03,,130.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.15,90,,146.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.08,88,,143.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.38,33.11,,53.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.43,183.15,
O/T WRIST NIGHT TIMER,3954,CDM,430,RC,L3908,HCPCS,Outpatient,,,203.5,122.1,,172.98,85,,138.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.86,80.03,,130.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.15,90,,146.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.08,88,,143.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.38,33.11,,53.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.43,183.15,
Therapy for speech or hearing,322004,CDM,440,RC,92507,HCPCS,Outpatient,,,203.5,122.1,,172.98,85,,138.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.86,80.03,,130.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,183.15,90,,146.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.08,88,,143.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.38,33.11,,53.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.43,183.15,
Therapy for speech or hearing,322009,CDM,440,RC,92507,HCPCS,Outpatient,,,203.5,122.1,,172.98,85,,138.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.86,80.03,,130.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,183.15,90,,146.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.08,88,,143.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.38,33.11,,53.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.43,183.15,
DO NOT USE,322019,CDM,440,RC,92506,HCPCS,Outpatient,,,203.5,122.1,,172.98,85,,138.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.86,80.03,,130.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.15,90,,146.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.43,32.15,,52.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.08,88,,143.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.38,33.11,,53.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.43,183.15,
X-ray of the lower spine 2-3 views,22039,CDM,320,RC,72100,HCPCS,Outpatient,,,203.77,122.26,,173.2,85,,138.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.51,32.15,,52.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.08,80.03,,130.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,183.39,90,,146.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.51,32.15,,52.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,65.51,32.15,,52.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.32,88,,143.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.47,33.11,,53.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.51,183.39,
TRAY FOLEY CATHETER 16FR,49574,CDM,270,RC,,,Outpatient,,,204.18,122.51,,173.55,85,,138.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.64,32.15,,52.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.41,80.03,,130.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.76,90,,147.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.64,32.15,,52.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.64,32.15,,52.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.68,88,,143.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.6,33.11,,54.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.64,183.76,
TRAY FOLEY CATHETER 18FR,49580,CDM,270,RC,,,Outpatient,,,204.18,122.51,,173.55,85,,138.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.64,32.15,,52.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.41,80.03,,130.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.76,90,,147.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.64,32.15,,52.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.64,32.15,,52.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.68,88,,143.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.6,33.11,,54.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.64,183.76,
METHAMPHETAMINES METABOLITE  (MAYO),1882145,CDM,300,RC,80324,HCPCS,Outpatient,,,204.25,122.55,,173.61,85,,138.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,163.46,80.03,,130.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.83,90,,147.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,179.74,88,,143.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.55,183.83,
Blood test for an STD,1882699,CDM,300,RC,87661,HCPCS,Outpatient,,,204.25,122.55,,173.61,85,,138.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,163.46,80.03,,130.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,183.83,90,,147.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,179.74,88,,143.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.42,183.83,
PELVIMETRY,22104,CDM,320,RC,74710,HCPCS,Outpatient,,,204.5,122.7,,173.83,85,,139.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.75,32.15,,52.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.66,80.03,,130.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,184.05,90,,147.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.75,32.15,,52.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,65.75,32.15,,52.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.96,88,,143.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.71,33.11,,54.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.75,184.05,
"CARBOXY-THC CONFIRM, MECONIUM  (MAYO)",1884409,CDM,300,RC,80349,HCPCS,Outpatient,,,204.54,122.72,,173.86,85,,139.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.76,32.15,,52.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.69,80.03,,130.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.09,90,,147.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.76,32.15,,52.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.76,32.15,,52.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,180,88,,144,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.72,33.11,,54.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.76,184.09,
ABDOMEN FLAT/UPRIGHT,22080,CDM,320,RC,74021,HCPCS,Outpatient,,,204.69,122.81,,173.99,85,,139.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.81,32.15,,52.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.81,80.03,,131.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,184.22,90,,147.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.81,32.15,,52.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,65.81,32.15,,52.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,180.13,88,,144.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.77,33.11,,54.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.81,184.22,
L/S CORSET WITH SNAPS AND LACES 30 - 52,314036,CDM,270,RC,K0642,HCPCS,Outpatient,,,205.25,123.15,,174.46,85,,139.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.99,32.15,,52.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.26,80.03,,131.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.73,90,,147.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.99,32.15,,52.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.99,32.15,,52.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,180.62,88,,144.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.96,33.11,,54.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.99,184.73,
GANGLIOSIDE AB (ANTI-GM1)  (MAYO),1883513,CDM,300,RC,83520,HCPCS,Outpatient,,,205.75,123.45,,174.89,85,,139.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,164.66,80.03,,131.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,185.18,90,,148.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,181.06,88,,144.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,185.18,
P/T STRAPPING OF THORAX,3907,CDM,420,RC,29200,HCPCS,Outpatient,,,206,123.6,,175.1,85,,140.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.23,32.15,,52.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.86,80.03,,131.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,185.4,90,,148.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.23,32.15,,52.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,66.23,32.15,,52.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,181.28,88,,145.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.21,33.11,,54.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.23,185.4,
O/T STRAPPING OF THORAX,3915,CDM,430,RC,29200,HCPCS,Outpatient,,,206,123.6,,175.1,85,,140.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.23,32.15,,52.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.86,80.03,,131.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,185.4,90,,148.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.23,32.15,,52.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,66.23,32.15,,52.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,181.28,88,,145.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.21,33.11,,54.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.23,185.4,
FLOW CYTOMETRY,2188180,CDM,310,RC,88187,HCPCS,Outpatient,,,206.25,123.75,,175.31,85,,140.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165.06,80.03,,132.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.63,90,,148.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,59.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,181.5,88,,145.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.57,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,59.78,185.63,
"ALPHA-GALACTOSIDASE, SERUM  (MAYO)",1882659,CDM,300,RC,82657,HCPCS,Outpatient,,,206.5,123.9,,175.53,85,,140.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165.26,80.03,,132.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,185.85,90,,148.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,181.72,88,,145.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,185.85,
XANAX  (MAYO),1880107,CDM,300,RC,80154,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
Blood test to assist with diagnosis,2188365,CDM,310,RC,88313,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,186.3,
SCOLIOSIS STUDY LIMITED,22031,CDM,320,RC,72020,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
MM STEREOTACTIC LOC DIAG,2276095,CDM,320,RC,76095,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
CONTRL ANT/NASL HEM COMPLEX,1430903,CDM,450,RC,30903,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.3,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.3,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
NASAL HEMOR/ANT/COMPL/BILAT,1430904,CDM,450,RC,30903,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.3,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.3,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
CONTRL POST/NASL HEMORR INIT SAME DAY,1430905,CDM,450,RC,30905,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.3,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.3,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
I & D ABSCESS DENTOALVEOLAR,1441800,CDM,450,RC,41800,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
SPRFICL CONJUNT FB REM,1465205,CDM,450,RC,65205,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
CORNEAL FB REM W/ SL/LP,1465222,CDM,450,RC,65222,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
US ASPIRATION OF THYROID,24035,CDM,402,RC,10022,HCPCS,Outpatient,,,207.25,124.35,,176.16,85,,140.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.63,32.15,,53.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.86,80.03,,132.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.53,90,,149.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.63,32.15,,53.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,66.63,32.15,,53.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.38,88,,145.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.62,33.11,,54.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.63,186.53,
LACOSAMIDE  (MAYO),1882484,CDM,300,RC,80299,HCPCS,Outpatient,,,207.75,124.65,,176.59,85,,141.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,166.26,80.03,,133.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,186.98,90,,149.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,182.82,88,,146.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,186.98,
P/T EVAL DO NOT USE AFTER 12/16,312,CDM,424,RC,97001,HCPCS,Outpatient,,,208,124.8,,176.8,85,,141.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.87,32.15,,53.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,166.46,80.03,,133.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.2,90,,149.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.87,32.15,,53.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,66.87,32.15,,53.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.04,88,,146.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.87,33.11,,55.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.87,187.2,
"THIOPURINE METABOLITE, 6-TGN  (MAYO)",1882062,CDM,300,RC,82542,HCPCS,Outpatient,,,208.25,124.95,,177.01,85,,141.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,166.66,80.03,,133.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,187.43,90,,149.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,183.26,88,,146.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,187.43,
"THIOPURINE METABOLITE, 6-MMPN  (MAYO)",1882063,CDM,300,RC,82542,HCPCS,Outpatient,,,208.25,124.95,,177.01,85,,141.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,166.66,80.03,,133.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,187.43,90,,149.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,183.26,88,,146.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,187.43,
PEPSINOGEN  (MAYO),1883517,CDM,300,RC,83519,HCPCS,Outpatient,,,208.75,125.25,,177.44,85,,141.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,167.06,80.03,,133.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,187.88,90,,150.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,183.7,88,,146.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,187.88,
OXYCODONE METABOLITE CONF URINE  (MAYO),1884698,CDM,300,RC,80365,HCPCS,Outpatient,,,209,125.4,,177.65,85,,142.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.19,32.15,,53.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.26,80.03,,133.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.1,90,,150.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.19,32.15,,53.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.19,32.15,,53.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.92,88,,147.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.2,33.11,,55.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.19,188.1,
CANISTER VAC 1000ML LARGE WITH GEL,49684,CDM,270,RC,,,Outpatient,,,209.25,125.55,,177.86,85,,142.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.27,32.15,,53.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.46,80.03,,133.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.33,90,,150.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.27,32.15,,53.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.27,32.15,,53.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.14,88,,147.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.28,33.11,,55.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.27,188.33,
Pathology test,2188339,CDM,310,RC,88342,HCPCS,Outpatient,,,209.5,125.7,,178.08,85,,142.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,167.66,80.03,,134.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,188.55,90,,150.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,184.36,88,,147.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,71.58,188.55,
TWIST ASSIST W/GAUGE,4900136,CDM,270,RC,,,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
"LUPUS PANEL, SLE  (MAYO)",1885304,CDM,300,RC,85300,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.08,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.08,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.9,188.78,
Radiologic examination of the finger(s),22219,CDM,320,RC,73140,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
PORT HIP UNILAT 1V LT,22227,CDM,320,RC,73501,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
PORT SINUSES <3V,22246,CDM,320,RC,70210,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
"Radiologic examination of the neck/spine, 2-3 views",22249,CDM,320,RC,72040,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
PORT STERNUM 2V,22254,CDM,320,RC,71120,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
Radiologic examination of the toe(s),22256,CDM,320,RC,73660,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
Radiologic examination of the toe(s),22359,CDM,320,RC,73660,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
US EMERGENCY CHARGE,24030,CDM,402,RC,76499,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
EXTERNAL PACEMAKER (ER),16035,CDM,732,RC,93012,HCPCS,Outpatient,,,209.75,125.85,,178.29,85,,142.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,167.86,80.03,,134.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.78,90,,151.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.43,32.15,,53.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.58,88,,147.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.45,33.11,,55.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.43,188.78,
"Removal of skin tags, multiple fibrocutaneous tags, any area",11200,CDM,761,RC,11200,HCPCS,Outpatient,,,210,126,,178.5,85,,142.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.52,32.15,,54.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.06,80.03,,134.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,189,90,,151.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.52,32.15,,54.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,67.52,32.15,,54.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.8,88,,147.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.53,33.11,,55.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.52,189,
PACK BASIC XI,498141,CDM,270,RC,,,Outpatient,,,210.31,126.19,,178.76,85,,143.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.61,32.15,,54.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.31,80.03,,134.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.28,90,,151.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.61,32.15,,54.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.61,32.15,,54.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.07,88,,148.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.63,33.11,,55.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.61,189.28,
RETRACTOR TRAXI PANNICULUS,49985,CDM,270,RC,,,Outpatient,,,210.5,126.3,,178.93,85,,143.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.68,32.15,,54.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.46,80.03,,134.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.45,90,,151.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.68,32.15,,54.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.68,32.15,,54.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.24,88,,148.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.7,33.11,,55.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.68,189.45,
BICILLIN CR 900/300 INJ,296011,CDM,636,RC,J0558,HCPCS,Outpatient,,,211,126.6,,179.35,85,,143.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,168.86,80.03,,135.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.05,102,,,fee schedule,Pays at 102% of CMS APC rate,189.9,90,,151.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.05,100,,,fee schedule,Pays at 100% of CMS APC rate,15.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,185.68,88,,148.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.74,189.9,
"BICILLIN CR : 600,000 INJ",296014,CDM,636,RC,J0570,HCPCS,Outpatient,,,211,126.6,,179.35,85,,143.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.86,80.03,,135.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1337.98,102,,,fee schedule,Pays at 102% of CMS APC rate,189.9,90,,151.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1337.98,100,,,fee schedule,Pays at 100% of CMS APC rate,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.68,88,,148.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.86,33.11,,55.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.84,189.9,
"BICILLIN CR:  600,000 U'S",296080,CDM,636,RC,J0570,HCPCS,Outpatient,,,211,126.6,,179.35,85,,143.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.86,80.03,,135.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1337.98,102,,,fee schedule,Pays at 102% of CMS APC rate,189.9,90,,151.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1337.98,100,,,fee schedule,Pays at 100% of CMS APC rate,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.68,88,,148.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.86,33.11,,55.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.84,189.9,
RED BLOOD CELL EACH,2086134,CDM,390,RC,P9021,HCPCS,Outpatient,,,211.23,126.74,,179.55,85,,143.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.91,32.15,,54.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.05,80.03,,135.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,138.22,102,,,fee schedule,Pays at 102% of CMS APC rate,190.11,90,,152.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.91,32.15,,54.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.22,100,,,fee schedule,Pays at 100% of CMS APC rate,67.91,32.15,,54.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.88,88,,148.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.94,33.11,,55.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.91,190.11,
BETHESDA UNITS (MAYO),188315,CDM,300,RC,85335,HCPCS,Outpatient,,,211.25,126.75,,179.56,85,,143.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,169.06,80.03,,135.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,190.13,90,,152.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,185.9,88,,148.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,190.13,
"PROCALCITONIN, SERUM  (MAYO)",1882688,CDM,300,RC,84145,HCPCS,Outpatient,,,211.25,126.75,,179.56,85,,143.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,169.06,80.03,,135.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,190.13,90,,152.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,185.9,88,,148.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.06,190.13,
O/T SELECTIVE DEBRIDEMENT,3959,CDM,420,RC,97601,HCPCS,Outpatient,,,211.25,126.75,,179.56,85,,143.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.92,32.15,,54.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.06,80.03,,135.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.13,90,,152.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.92,32.15,,54.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.92,32.15,,54.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.9,88,,148.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.94,33.11,,55.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.92,190.13,
Test to measure arterial blood gases,1882803,CDM,300,RC,82803,HCPCS,Outpatient,,,212,127.2,,180.2,85,,144.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,169.66,80.03,,135.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,190.8,90,,152.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,186.56,88,,149.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.34,190.8,
O/T NON-SELECTIVE DEBRIDEMENT,3960,CDM,430,RC,97602,HCPCS,Outpatient,,,213,127.8,,181.05,85,,144.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.48,32.15,,54.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.46,80.03,,136.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,191.7,90,,153.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.48,32.15,,54.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,68.48,32.15,,54.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,187.44,88,,149.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.52,33.11,,56.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.48,191.7,
Blood test to measure the amount of iron that is in transit in the body,1883540,CDM,300,RC,83540,HCPCS,Outpatient,,,213.25,127.95,,181.26,85,,145.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,170.66,80.03,,136.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,191.93,90,,153.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.15,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,187.66,88,,150.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.15,191.93,
MATTRESS ACUCAIR,49005,CDM,270,RC,,,Outpatient,,,213.5,128.1,,181.48,85,,145.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.86,80.03,,136.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.15,90,,153.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,187.88,88,,150.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.69,33.11,,56.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.64,192.15,
KIT COLO/ILEOSTOMY 1 3/4,493225,CDM,270,RC,,,Outpatient,,,213.5,128.1,,181.48,85,,145.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.86,80.03,,136.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.15,90,,153.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,187.88,88,,150.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.69,33.11,,56.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.64,192.15,
KIT COLO/ILEOSTOMY 2 3/4,493226,CDM,270,RC,,,Outpatient,,,213.5,128.1,,181.48,85,,145.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.86,80.03,,136.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.15,90,,153.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,187.88,88,,150.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.69,33.11,,56.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.64,192.15,
O/T TENNIS ELBOW STRAP FIT/ADJ,3949,CDM,274,RC,L3701,HCPCS,Outpatient,,,213.5,128.1,,181.48,85,,145.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.86,80.03,,136.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.15,90,,153.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.64,32.15,,54.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,187.88,88,,150.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.69,33.11,,56.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.64,192.15,
GALLBLADDER REPEAT,22090,CDM,320,RC,74290,HCPCS,Outpatient,,,213.75,128.25,,181.69,85,,145.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.72,32.15,,54.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.06,80.03,,136.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,192.38,90,,153.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.72,32.15,,54.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,68.72,32.15,,54.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.1,88,,150.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.77,33.11,,56.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.72,192.38,
"COCAINE/METAB. CONFIRM, MECONIUM  (MAYO)",1882655,CDM,300,RC,80353,HCPCS,Outpatient,,,214,128.4,,181.9,85,,145.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,171.26,80.03,,137.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.6,90,,154.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,12.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,188.32,88,,150.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.06,192.6,
"DIPHENHYDRAMINE, QT SERUM/PLASMA  (MAYO)",1882221,CDM,300,RC,84999,HCPCS,Outpatient,,,214.25,128.55,,182.11,85,,145.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.88,32.15,,55.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.46,80.03,,137.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.83,90,,154.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.88,32.15,,55.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.88,32.15,,55.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.54,88,,150.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.94,33.11,,56.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.88,192.83,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,8411401,CDM,761,RC,11401,HCPCS,Outpatient,,,214.25,128.55,,182.11,85,,145.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.88,32.15,,55.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.46,80.03,,137.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,192.83,90,,154.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.88,32.15,,55.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,68.88,32.15,,55.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.54,88,,150.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.94,33.11,,56.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.88,192.83,
"ANCA, IBD SCREEN WITH REFLEX  (MAYO)",1886020,CDM,300,RC,86021,HCPCS,Outpatient,,,215,129,,182.75,85,,146.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,172.06,80.03,,137.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.35,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,193.5,90,,154.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.35,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,189.2,88,,151.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.93,193.5,
TUBE ENDOBRONCHIAL 37FR LEFT,493853,CDM,270,RC,,,Outpatient,,,215.25,129.15,,182.96,85,,146.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.2,32.15,,55.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.26,80.03,,137.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.73,90,,154.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.2,32.15,,55.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,69.2,32.15,,55.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.42,88,,151.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.27,33.11,,57.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.2,193.73,
EXTERNAL PACING,14150,CDM,270,RC,,,Outpatient,,,215.75,129.45,,183.39,85,,146.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.36,32.15,,55.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.66,80.03,,138.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.18,90,,155.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.36,32.15,,55.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,69.36,32.15,,55.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.86,88,,151.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.43,33.11,,57.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.36,194.18,
RAPID VOLUME USE,14200,CDM,450,RC,,,Outpatient,,,215.75,129.45,,183.39,85,,146.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.36,32.15,,55.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.66,80.03,,138.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.18,90,,155.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.36,32.15,,55.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,69.36,32.15,,55.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.86,88,,151.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.43,33.11,,57.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.36,194.18,
P/T STRAPPING OF HIP,3903,CDM,420,RC,29520,HCPCS,Outpatient,,,216.25,129.75,,183.81,85,,147.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.06,80.03,,138.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,194.63,90,,155.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.3,88,,152.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.6,33.11,,57.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.52,194.63,
P/T STRAPPING OF SHOULDER,3909,CDM,420,RC,29240,HCPCS,Outpatient,,,216.25,129.75,,183.81,85,,147.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.06,80.03,,138.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,194.63,90,,155.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.3,88,,152.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.6,33.11,,57.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.52,194.63,
O/T STRAPPING OF SHOULDER,3912,CDM,430,RC,29240,HCPCS,Outpatient,,,216.25,129.75,,183.81,85,,147.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.06,80.03,,138.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,194.63,90,,155.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,69.52,32.15,,55.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.3,88,,152.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.6,33.11,,57.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.52,194.63,
BIOPSY OF MUSCLE,22340,CDM,320,RC,20206,HCPCS,Outpatient,,,216.75,130.05,,184.24,85,,147.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.69,32.15,,55.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.47,80.03,,138.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,195.08,90,,156.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.69,32.15,,55.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,69.69,32.15,,55.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.74,88,,152.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.77,33.11,,57.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.69,195.08,
CD20 TOTAL COUNT  (MAYO),1882697,CDM,300,RC,86356,HCPCS,Outpatient,,,217,130.2,,184.45,85,,147.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,173.67,80.03,,138.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,27.31,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,195.3,90,,156.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.31,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,32.83,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,190.96,88,,152.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.83,195.3,
FLUORO GUIDE NEEDLE PLACEMENT,22172,CDM,320,RC,77003,HCPCS,Outpatient,,,217.25,130.35,,184.66,85,,147.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.87,80.03,,139.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.53,90,,156.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.18,88,,152.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.93,33.11,,57.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.85,195.53,
BENTYL (dicyclomine) 10MG/ML : 2ML AMP,293025,CDM,636,RC,J0500,HCPCS,Outpatient,,,217.44,130.46,,184.82,85,,147.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,174.02,80.03,,139.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.7,90,,156.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,21.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,191.35,88,,153.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.45,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.8,195.7,
"ANTIMULLERIAN HORMONE, SERUM  (MAYO)",1882215,CDM,300,RC,83520,HCPCS,Outpatient,,,217.75,130.65,,185.09,85,,148.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,174.27,80.03,,139.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,195.98,90,,156.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,191.62,88,,153.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,195.98,
BLADE SAGITTAL FINE TOOTH,499813,CDM,270,RC,,,Outpatient,,,218.13,130.88,,185.41,85,,148.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.13,32.15,,56.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,174.57,80.03,,139.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,196.32,90,,157.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.13,32.15,,56.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.13,32.15,,56.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.95,88,,153.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.22,33.11,,57.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.13,196.32,
"PROSTATE TRIPLE VIEW, TC  (IO)",2188366,CDM,310,RC,88344,HCPCS,Outpatient,,,218.5,131.1,,185.73,85,,148.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,174.87,80.03,,139.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,196.65,90,,157.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,192.28,88,,153.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,99.31,196.65,
BK VIRUS URINE (PCR)  (MAYO),1887802,CDM,300,RC,87799,HCPCS,Outpatient,,,219.25,131.55,,186.36,85,,149.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.49,32.15,,56.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.47,80.03,,140.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,43.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,197.33,90,,157.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.49,32.15,,56.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,70.49,32.15,,56.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,192.94,88,,154.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.59,33.11,,58.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.49,197.33,
"IMMUNHISTOCHEM STAIN, TC  (CSI)",2188343,CDM,310,RC,88344,HCPCS,Outpatient,,,219.25,131.55,,186.36,85,,149.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,175.47,80.03,,140.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,197.33,90,,157.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,192.94,88,,154.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,99.31,197.33,
Test to determine how well oxygen moves from the lungs to the blood stream,30077,CDM,460,RC,94010,HCPCS,Outpatient,,,219.25,131.55,,186.36,85,,149.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.49,32.15,,56.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.47,80.03,,140.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,197.33,90,,157.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.49,32.15,,56.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,70.49,32.15,,56.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,192.94,88,,154.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.59,33.11,,58.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.49,197.33,
THORAZINE CONC 100MG/ML : BOTTLE,292293,CDM,250,RC,,,Outpatient,,,219.5,131.7,,186.58,85,,149.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.57,32.15,,56.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.67,80.03,,140.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.55,90,,158.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.57,32.15,,56.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.57,32.15,,56.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.16,88,,154.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.68,33.11,,58.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.57,197.55,
Test to measure arterial blood gases,1882804,CDM,300,RC,82803,HCPCS,Outpatient,,,219.5,131.7,,186.58,85,,149.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,175.67,80.03,,140.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,26.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,197.55,90,,158.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,193.16,88,,154.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.34,197.55,
AC JOINTS,22054,CDM,320,RC,73050,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
Radiologic examination of the collar bone,22213,CDM,320,RC,73000,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
Radiologic examination of the foot with 3 or more views,22220,CDM,320,RC,73630,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
Radiologic examination of the forearm,22221,CDM,320,RC,73090,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
PORT HUMERUS 2V LT,22228,CDM,320,RC,73060,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
PORT NASAL BONES 3V,22233,CDM,320,RC,70160,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
Radiologic examination of the ankle with 3 views,22299,CDM,320,RC,73610,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
PORT HUMERUS 2V RT,22352,CDM,320,RC,73060,HCPCS,Outpatient,,,219.75,131.85,,186.79,85,,149.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,175.87,80.03,,140.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,197.78,90,,158.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,70.65,32.15,,56.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,88,,154.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.76,33.11,,58.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.65,197.78,
QVAR (beclomethasone) HFA 80 MCG INHALER,291040,CDM,250,RC,,,Outpatient,,,220,132,,187,85,,149.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.73,32.15,,56.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.07,80.03,,140.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198,90,,158.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.73,32.15,,56.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220,,,,Other,Not Separately reimbursable,70.73,32.15,,56.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.6,88,,154.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,72.84,33.11,,58.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.73,198,
"IMMUNOFIX, ELECTRO W\CONC U  (MAYO)",1884192,CDM,300,RC,86335,HCPCS,Outpatient,,,220,132,,187,85,,149.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,176.07,80.03,,140.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,29.93,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,198,90,,158.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.93,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,36.9,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,193.6,88,,154.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.9,198,
".IMMUNOFIXATION, SERUM  ONLY (MAYO)",1886320,CDM,300,RC,86334,HCPCS,Outpatient,,,220,132,,187,85,,149.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,176.07,80.03,,140.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,198,90,,158.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,193.6,88,,154.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.09,198,
COAG FACTOR XII ASSAY P (MAYO),1885314,CDM,300,RC,85280,HCPCS,Outpatient,,,220.5,132.3,,187.43,85,,149.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,176.47,80.03,,141.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,198.45,90,,158.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,194.04,88,,155.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.34,198.45,
Blood test to monitor for cytomegalovirus,1887009,CDM,300,RC,86644,HCPCS,Outpatient,,,220.5,132.3,,187.43,85,,149.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,176.47,80.03,,141.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.67,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,198.45,90,,158.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.67,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,194.04,88,,155.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.63,198.45,
STAYS ELASTIC SURGICAL,490161,CDM,270,RC,,,Outpatient,,,220.75,132.45,,187.64,85,,150.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.97,32.15,,56.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.67,80.03,,141.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.68,90,,158.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.97,32.15,,56.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.75,,,,Other,Not Separately reimbursable,70.97,32.15,,56.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.26,88,,155.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.09,33.11,,58.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,70.97,198.68,
UROGRAPHY RETROGRADE WWO KUB,22166,CDM,320,RC,74420,HCPCS,Outpatient,,,221.07,132.64,,187.91,85,,150.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.07,32.15,,56.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.92,80.03,,141.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,198.96,90,,159.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.07,32.15,,56.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,71.07,32.15,,56.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.54,88,,155.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.2,33.11,,58.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.07,198.96,
TBC STAT FEE,20004,CDM,270,RC,,,Outpatient,,,221.25,132.75,,188.06,85,,150.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.07,80.03,,141.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.13,90,,159.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,221.25,,,,Other,Not Separately reimbursable,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.7,88,,155.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.26,33.11,,58.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.13,199.13,
TBC STAT FEE,29004,CDM,270,RC,,,Outpatient,,,221.25,132.75,,188.06,85,,150.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.07,80.03,,141.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.13,90,,159.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,221.25,,,,Other,Not Separately reimbursable,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.7,88,,155.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.26,33.11,,58.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.13,199.13,
Serial radiologic examination of the abdomen,22081,CDM,320,RC,74022,HCPCS,Outpatient,,,221.25,132.75,,188.06,85,,150.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.07,80.03,,141.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,199.13,90,,159.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,71.13,32.15,,56.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.7,88,,155.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.26,33.11,,58.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.13,199.13,
MASTOIDS 3V PER SIDE,22004,CDM,320,RC,70130,HCPCS,Outpatient,,,221.5,132.9,,188.28,85,,150.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.21,32.15,,56.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.27,80.03,,141.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,199.35,90,,159.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.21,32.15,,56.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,71.21,32.15,,56.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.92,88,,155.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.34,33.11,,58.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.21,199.35,
OPTIC FORAMINA,22009,CDM,320,RC,70190,HCPCS,Outpatient,,,221.5,132.9,,188.28,85,,150.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.21,32.15,,56.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.27,80.03,,141.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,199.35,90,,159.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.21,32.15,,56.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,71.21,32.15,,56.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.92,88,,155.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.34,33.11,,58.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.21,199.35,
Draining or injecting medication into a large joint/bursa without ultrasound,22164,CDM,320,RC,20605,HCPCS,Outpatient,,,222.25,133.35,,188.91,85,,151.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.45,32.15,,57.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,177.87,80.03,,142.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,200.03,90,,160.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.45,32.15,,57.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,71.45,32.15,,57.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.58,88,,156.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.59,33.11,,58.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.45,200.03,
PILOCARPINE 1% OPTH SOLN 15 ML,297741,CDM,250,RC,,,Outpatient,,,222.55,133.53,,189.17,85,,151.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.55,32.15,,57.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.11,80.03,,142.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.3,90,,160.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.55,32.15,,57.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,222.55,,,,Other,Not Separately reimbursable,71.55,32.15,,57.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.84,88,,156.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.69,33.11,,58.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.55,200.3,
CUSTOM STATIC SPLINT,593002,CDM,270,RC,,,Outpatient,,,222.65,133.59,,189.25,85,,151.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.58,32.15,,57.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.19,80.03,,142.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.39,90,,160.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.58,32.15,,57.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,222.65,,,,Other,Not Separately reimbursable,71.58,32.15,,57.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.93,88,,156.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.72,33.11,,58.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.58,200.39,
DIRECT DONOR        (TBC),2086128,CDM,390,RC,,,Outpatient,,,222.75,133.65,,189.34,85,,151.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.61,32.15,,57.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.27,80.03,,142.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.48,90,,160.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.61,32.15,,57.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,222.75,,,,Other,Not Separately reimbursable,71.61,32.15,,57.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.02,88,,156.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.75,33.11,,59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.61,200.48,
"RAST, CHILDHOOD PANEL  (MAYO)",1886003,CDM,300,RC,82785,HCPCS,Outpatient,,,223.25,133.95,,189.76,85,,151.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,178.67,80.03,,142.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,200.93,90,,160.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,196.46,88,,157.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.71,200.93,
"HISTOPLASMA  AG, URINE  (MAYO)",1887385,CDM,300,RC,87385,HCPCS,Outpatient,,,223.5,134.1,,189.98,85,,151.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,178.87,80.03,,143.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,201.15,90,,160.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,196.68,88,,157.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,201.15,
O/T EVAL DO NOT USE AFTER 12/2016,3121,CDM,434,RC,97003,HCPCS,Outpatient,,,223.5,134.1,,189.98,85,,151.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.86,32.15,,57.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.87,80.03,,143.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.15,90,,160.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.86,32.15,,57.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.5,,,,Other,Not Separately reimbursable,71.86,32.15,,57.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.68,88,,157.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74,33.11,,59.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.86,201.15,
AMIKIN(amikacin): 500MG VIAL,293394,CDM,636,RC,J0278,HCPCS,Outpatient,,,224.03,134.42,,190.43,85,,152.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,179.29,80.03,,143.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.63,90,,161.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,224.03,,,,Other,Not Separately reimbursable,0.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,197.15,88,,157.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.94,201.63,
"MONOCLONAL PROTEIN EXP, URINE  (MAYO)",1884205,CDM,300,RC,84165,HCPCS,Outpatient,,,224.25,134.55,,190.61,85,,152.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,179.47,80.03,,143.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,10.95,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,201.83,90,,161.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10.95,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,197.34,88,,157.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.51,201.83,
N-TELEPEPTIDE SERUM  (MAYO),1882524,CDM,300,RC,82523,HCPCS,Outpatient,,,224.5,134.7,,190.83,85,,152.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,179.67,80.03,,143.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.05,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,202.05,90,,161.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.05,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,197.56,88,,158.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.21,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.5,202.05,
QUANTIFERON (AFB) GOLD  (MAYO),1886480,CDM,300,RC,86480,HCPCS,Outpatient,,,224.5,134.7,,190.83,85,,152.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,179.67,80.03,,143.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.21,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,202.05,90,,161.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,63.21,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,77.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,197.56,88,,158.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.27,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,77.93,202.05,
KIT COLO/ILEO SUR-FIT GENTLE TOUCH 2 3/4,493216,CDM,270,RC,,,Outpatient,,,224.75,134.85,,191.04,85,,152.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.87,80.03,,143.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.28,90,,161.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.75,,,,Other,Not Separately reimbursable,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.78,88,,158.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.41,33.11,,59.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.26,202.28,
CT REFORMAT,26074,CDM,350,RC,76376,HCPCS,Outpatient,,,224.75,134.85,,191.04,85,,152.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.87,80.03,,143.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.28,90,,161.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.75,,,,Other,Not Separately reimbursable,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.78,88,,158.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.41,33.11,,59.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.26,202.28,
CT 3D RECONSTRUCTION,26100,CDM,352,RC,76376,HCPCS,Outpatient,,,224.75,134.85,,191.04,85,,152.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.87,80.03,,143.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.28,90,,161.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.75,,,,Other,Not Separately reimbursable,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.78,88,,158.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.41,33.11,,59.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.26,202.28,
DO NOT USE,3220011,CDM,440,RC,92506,HCPCS,Outpatient,,,224.75,134.85,,191.04,85,,152.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.87,80.03,,143.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.28,90,,161.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.75,,,,Other,Not Separately reimbursable,72.26,32.15,,57.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.78,88,,158.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.41,33.11,,59.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.26,202.28,
HB VARIANT BY MASS SPEC  (MAYO),1882693,CDM,300,RC,83789,HCPCS,Outpatient,,,225,135,,191.25,85,,153,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,180.07,80.03,,144.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,202.5,90,,162,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,198,88,,158.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,202.5,
IV CHEMO 1 HOUR,2996413,CDM,335,RC,96413,HCPCS,Outpatient,,,225,135,,191.25,85,,153,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.34,32.15,,57.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,180.07,80.03,,144.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,318.87,102,,,fee schedule,Pays at 102% of CMS APC rate,202.5,90,,162,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.34,32.15,,57.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.87,100,,,fee schedule,Pays at 100% of CMS APC rate,72.34,32.15,,57.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198,88,,158.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.5,33.11,,59.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.34,202.5,
IMMUNOFIXATION SERUM ONLY  (MAYO),1882781,CDM,300,RC,86334,HCPCS,Outpatient,,,225.75,135.45,,191.89,85,,153.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,180.67,80.03,,144.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,203.18,90,,162.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,198.66,88,,158.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.93,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.09,203.18,
TISSUE MARKER ULTRACLIP II,491436,CDM,270,RC,A4648,HCPCS,Outpatient,,,226.5,135.9,,192.53,85,,154.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.82,32.15,,58.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,181.27,80.03,,145.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.85,90,,163.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.82,32.15,,58.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,226.5,,,,Other,Not Separately reimbursable,72.82,32.15,,58.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.32,88,,159.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.99,33.11,,59.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.82,203.85,
NM Tc99 ULTRAGTAG,23054,CDM,250,RC,A9560,HCPCS,Outpatient,,,226.8,136.08,,192.78,85,,154.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.92,32.15,,58.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,181.51,80.03,,145.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.12,90,,163.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.92,32.15,,58.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,226.8,,,,Other,Not Separately reimbursable,72.92,32.15,,58.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.58,88,,159.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.09,33.11,,60.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.92,204.12,
NM DTPA,2932280,CDM,343,RC,A9567,HCPCS,Outpatient,,,227.17,136.3,,193.09,85,,154.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.04,32.15,,58.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,181.8,80.03,,145.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.45,90,,163.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.04,32.15,,58.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.17,,,,Other,Not Separately reimbursable,73.04,32.15,,58.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.91,88,,159.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.22,33.11,,60.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.04,204.45,
OFF-LOADER CUTIMED SELECT,49290,CDM,270,RC,,,Outpatient,,,227.25,136.35,,193.16,85,,154.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.06,32.15,,58.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,181.87,80.03,,145.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.53,90,,163.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.06,32.15,,58.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.25,,,,Other,Not Separately reimbursable,73.06,32.15,,58.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.98,88,,159.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.24,33.11,,60.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.06,204.53,
INTERSTIM,4999941,CDM,278,RC,C1767,HCPCS,Outpatient,,,227.25,136.35,,193.16,85,,154.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.06,32.15,,58.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,181.87,80.03,,145.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.53,90,,163.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.06,32.15,,58.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.25,,,,Other,Not Separately reimbursable,73.06,32.15,,58.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.98,88,,159.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.24,33.11,,60.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.06,204.53,
BAG COLLECTION FECAL FLEXISEAL,4980074,CDM,270,RC,,,Outpatient,,,227.5,136.5,,193.38,85,,154.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.14,32.15,,58.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.07,80.03,,145.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.75,90,,163.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.14,32.15,,58.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.5,,,,Other,Not Separately reimbursable,73.14,32.15,,58.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,200.2,88,,160.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.33,33.11,,60.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.14,204.75,
"HEXOKINASE, B  (MAYO)",1882965,CDM,300,RC,82657,HCPCS,Outpatient,,,228,136.8,,193.8,85,,155.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,182.47,80.03,,145.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,205.2,90,,164.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,200.64,88,,160.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,205.2,
PRO CT BONE DENSITY,26030,CDM,352,RC,77078,HCPCS,Outpatient,,,228,136.8,,193.8,85,,155.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.3,32.15,,58.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.47,80.03,,145.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,205.2,90,,164.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.3,32.15,,58.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,73.3,32.15,,58.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,200.64,88,,160.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.49,33.11,,60.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.3,205.2,
OLUMIANT (baricitinib) 2MG TABS,304532,CDM,250,RC,,,Outpatient,,,228.33,137,,194.08,85,,155.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.41,32.15,,58.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.73,80.03,,146.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.5,90,,164.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.41,32.15,,58.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.33,,,,Other,Not Separately reimbursable,73.41,32.15,,58.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,200.93,88,,160.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.6,33.11,,60.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.41,205.5,
AVITENE,298022,CDM,250,RC,,,Outpatient,,,228.41,137.05,,194.15,85,,155.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.43,32.15,,58.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.8,80.03,,146.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.57,90,,164.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.43,32.15,,58.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.41,,,,Other,Not Separately reimbursable,73.43,32.15,,58.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,201,88,,160.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.63,33.11,,60.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.43,205.57,
SNARE SINGULAR M-LRG OVAL,4988023,CDM,270,RC,,,Outpatient,,,229,137.4,,194.65,85,,155.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.62,32.15,,58.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.27,80.03,,146.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.1,90,,164.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.62,32.15,,58.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229,,,,Other,Not Separately reimbursable,73.62,32.15,,58.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,201.52,88,,161.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.82,33.11,,60.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.62,206.1,
Radiologic examination of one side of the chest/ribs,22240,CDM,320,RC,71101,HCPCS,Outpatient,,,229,137.4,,194.65,85,,155.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.62,32.15,,58.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.27,80.03,,146.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,206.1,90,,164.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.62,32.15,,58.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,73.62,32.15,,58.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,201.52,88,,161.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.82,33.11,,60.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.62,206.1,
MARIJUANA (THC) DRUG CONFIRMAT  (MAYO),1884408,CDM,300,RC,80349,HCPCS,Outpatient,,,229.25,137.55,,194.86,85,,155.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.7,32.15,,58.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.47,80.03,,146.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.33,90,,165.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.7,32.15,,58.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,73.7,32.15,,58.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,201.74,88,,161.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.9,33.11,,60.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.7,206.33,
"Flexible, fiberoptic diagnostic laryngoscopy",11006,CDM,761,RC,31575,HCPCS,Outpatient,,,229.75,137.85,,195.29,85,,156.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.86,32.15,,59.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.87,80.03,,147.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,171.36,102,,,fee schedule,Pays at 102% of CMS APC rate,206.78,90,,165.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.86,32.15,,59.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.36,100,,,fee schedule,Pays at 100% of CMS APC rate,73.86,32.15,,59.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.18,88,,161.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.07,33.11,,60.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.86,206.78,
TRAY CATH VESSEL UMBILICAL DISPOSABLE,49581,CDM,270,RC,,,Outpatient,,,230,138,,195.5,85,,156.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.95,32.15,,59.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.07,80.03,,147.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207,90,,165.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.95,32.15,,59.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,73.95,32.15,,59.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.4,88,,161.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.15,33.11,,60.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.95,207,
TYGACIL  (tigecycline)100MG /NS 100ML PB,293497,CDM,636,RC,J3243,HCPCS,Outpatient,,,230,138,,195.5,85,,156.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.95,32.15,,59.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.07,80.03,,147.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207,90,,165.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.95,32.15,,59.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,73.95,32.15,,59.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.4,88,,161.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.15,33.11,,60.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.95,207,
TRAY SUTURE DISPOSABLE,49261,CDM,270,RC,,,Outpatient,,,230.31,138.19,,195.76,85,,156.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.04,32.15,,59.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.32,80.03,,147.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.28,90,,165.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.04,32.15,,59.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,74.04,32.15,,59.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.67,88,,162.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.26,33.11,,61.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.04,207.28,
MRI  REFORMAT,27092,CDM,610,RC,76376,HCPCS,Outpatient,,,230.5,138.3,,195.93,85,,156.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.11,32.15,,59.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.47,80.03,,147.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.45,90,,165.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.11,32.15,,59.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,74.11,32.15,,59.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.84,88,,162.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.32,33.11,,61.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.11,207.45,
CORTROSYN (cosyntropin) 250MCG: INJ,293047,CDM,636,RC,J0834,HCPCS,Outpatient,,,230.97,138.58,,196.32,85,,157.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,184.85,80.03,,147.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.87,90,,166.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,32.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,203.25,88,,162.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.68,207.87,
P/T MULTI STATUS WOUNDS,3929,CDM,420,RC,97799,HCPCS,Outpatient,,,231,138.6,,196.35,85,,157.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.27,32.15,,59.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.87,80.03,,147.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,90,,166.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.27,32.15,,59.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,74.27,32.15,,59.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.28,88,,162.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.48,33.11,,61.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.27,207.9,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,93922,CDM,921,RC,93922,HCPCS,Outpatient,,,231.75,139.05,,196.99,85,,157.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.51,32.15,,59.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.47,80.03,,148.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,208.58,90,,166.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.51,32.15,,59.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,74.51,32.15,,59.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.94,88,,163.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.73,33.11,,61.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.51,208.58,
IMURAN (azathioprine) 100mg INJ,293540,CDM,636,RC,J7501,HCPCS,Outpatient,,,231.8,139.08,,197.03,85,,157.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.52,32.15,,59.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.51,80.03,,148.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,242.58,102,,,fee schedule,Pays at 102% of CMS APC rate,208.62,90,,166.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.52,32.15,,59.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,242.58,100,,,fee schedule,Pays at 100% of CMS APC rate,74.52,32.15,,59.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.98,88,,163.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.75,33.11,,61.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.52,208.62,
DO NOT USE,322001,CDM,440,RC,92506,HCPCS,Outpatient,,,232.5,139.5,,197.63,85,,158.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.75,32.15,,59.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,186.07,80.03,,148.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.25,90,,167.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.75,32.15,,59.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,74.75,32.15,,59.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.6,88,,163.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.98,33.11,,61.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.75,209.25,
RBC PHENOTYPE PANEL (13 ANTIGENS) (TBC),1887810,CDM,300,RC,86905,HCPCS,Outpatient,,,233,139.8,,198.05,85,,158.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,186.47,80.03,,149.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,209.7,90,,167.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,4.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,205.04,88,,164.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.81,209.7,
"MORPHO ANALYSIS, IN SITU EACH  (CSI)",1888369,CDM,310,RC,88368,HCPCS,Outpatient,,,233,139.8,,198.05,85,,158.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,169.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,186.47,80.03,,149.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,209.7,90,,167.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,169.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,169.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,205.04,88,,164.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,174.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,169.57,209.7,
HYLENEX (hyaluronidase) 150UNITS,293295,CDM,250,RC,,,Outpatient,,,233.35,140.01,,198.35,85,,158.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.02,32.15,,60.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,186.75,80.03,,149.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.02,90,,168.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.02,32.15,,60.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.02,32.15,,60.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.35,88,,164.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.26,33.11,,61.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.02,210.02,
O/T PRE-FORMED DYNAMIC PRONATION/SUPINAT,410,CDM,430,RC,E1802,HCPCS,Outpatient,,,233.45,140.07,,198.43,85,,158.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.05,32.15,,60.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,186.83,80.03,,149.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.11,90,,168.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.05,32.15,,60.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.05,32.15,,60.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.44,88,,164.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.3,33.11,,61.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.05,210.11,
BINDER ABDOMINAL 12  30-45 INCH,491149,CDM,270,RC,,,Outpatient,,,234.5,140.7,,199.33,85,,159.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.39,32.15,,60.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,187.67,80.03,,150.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.05,90,,168.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.39,32.15,,60.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.39,32.15,,60.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.36,88,,165.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.64,33.11,,62.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.39,211.05,
"New patient office or other outpatient visit, typically 10 minutes",99202,CDM,510,RC,99202,HCPCS,Outpatient,,,235,141,,199.75,85,,159.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.55,32.15,,60.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.07,80.03,,150.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.5,90,,169.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.55,32.15,,60.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.55,32.15,,60.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.8,88,,165.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.81,33.11,,62.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.55,211.5,
"UROBILINOGEN, STOOL  (MAYO)",1884577,CDM,300,RC,84577,HCPCS,Outpatient,,,235.25,141.15,,199.96,85,,159.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,188.27,80.03,,150.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.13,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,211.73,90,,169.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.13,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,207.02,88,,165.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.05,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.79,211.73,
DRAIN C.P. UNITE 2-BOTTLE,493008,CDM,270,RC,,,Outpatient,,,235.5,141.3,,200.18,85,,160.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.47,80.03,,150.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.95,90,,169.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.24,88,,165.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.97,33.11,,62.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.71,211.95,
DUAL ACESS LINE,494005,CDM,270,RC,,,Outpatient,,,235.5,141.3,,200.18,85,,160.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.47,80.03,,150.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.95,90,,169.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.24,88,,165.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.97,33.11,,62.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.71,211.95,
TRAY SUBCLAVIAN ARROW PEDIATRICS,497402,CDM,270,RC,,,Outpatient,,,235.5,141.3,,200.18,85,,160.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.47,80.03,,150.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.95,90,,169.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.71,32.15,,60.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.24,88,,165.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.97,33.11,,62.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.71,211.95,
Blood test to evaluate thyroid function,1884484,CDM,300,RC,84439,HCPCS,Outpatient,,,235.5,141.3,,200.18,85,,160.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,188.47,80.03,,150.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,211.95,90,,169.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,11.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,207.24,88,,165.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,11.34,211.95,
EACH ADDITIONAL NAIL PLATE,1411732,CDM,450,RC,11732,HCPCS,Outpatient,,,236,141.6,,200.6,85,,160.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.87,32.15,,60.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.87,80.03,,151.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.4,90,,169.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.87,32.15,,60.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.87,32.15,,60.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.68,88,,166.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.14,33.11,,62.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.87,212.4,
EKG 12 LEADS TRACING ONLY,1493005,CDM,730,RC,93005,HCPCS,Outpatient,,,236.25,141.75,,200.81,85,,160.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.95,32.15,,60.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.07,80.03,,151.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,212.63,90,,170.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.95,32.15,,60.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,75.95,32.15,,60.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.9,88,,166.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.22,33.11,,62.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.95,212.63,
AVULSION OF NAIL  PLATE EACH ADDT'L NAIL,11732,CDM,761,RC,11732,HCPCS,Outpatient,,,236.25,141.75,,200.81,85,,160.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.95,32.15,,60.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.07,80.03,,151.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.63,90,,170.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.95,32.15,,60.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.95,32.15,,60.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.9,88,,166.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.22,33.11,,62.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.95,212.63,
"DRESSING, VAC BRIDGE DRESSING",4383,CDM,270,RC,,,Outpatient,,,236.5,141.9,,201.03,85,,160.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.27,80.03,,151.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.85,90,,170.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,208.12,88,,166.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.31,33.11,,62.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.03,212.85,
CYSTIC FIBROSIS SCREEN  (MAYO),1883893,CDM,300,RC,83890,HCPCS,Outpatient,,,236.5,141.9,,201.03,85,,160.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.27,80.03,,151.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.85,90,,170.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,208.12,88,,166.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.31,33.11,,62.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.03,212.85,
EPIDURAL POST-OP PAIN,13032,CDM,370,RC,,,Outpatient,,,236.5,141.9,,201.03,85,,160.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.27,80.03,,151.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.85,90,,170.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.03,32.15,,60.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,208.12,88,,166.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.31,33.11,,62.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.03,212.85,
Radiologic examination of the shoulder,22455,CDM,320,RC,73030,HCPCS,Outpatient,,,236.78,142.07,,201.26,85,,161.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.12,32.15,,60.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.5,80.03,,151.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,213.1,90,,170.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.12,32.15,,60.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,76.12,32.15,,60.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,208.37,88,,166.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.4,33.11,,62.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.12,213.1,
P/T EVAL MOD COMPLEXITY,3197162,CDM,424,RC,97162,HCPCS,Outpatient,,,236.78,142.07,,201.26,85,,161.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.12,32.15,,60.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.5,80.03,,151.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,97.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,213.1,90,,170.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.12,32.15,,60.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,76.12,32.15,,60.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,208.37,88,,166.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.4,33.11,,62.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.12,213.1,
LISDEXAMFETAMINE DIMESYLATE  (MAYO),1882045,CDM,300,RC,80324,HCPCS,Outpatient,,,237.5,142.5,,201.88,85,,161.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,190.07,80.03,,152.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.75,90,,171,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,19.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,209,88,,167.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.55,213.75,
SUTURE GORETEX MONOFILAMENT CV-2,4993355,CDM,270,RC,,,Outpatient,,,237.75,142.65,,202.09,85,,161.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.44,32.15,,61.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.27,80.03,,152.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.98,90,,171.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.44,32.15,,61.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.44,32.15,,61.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.22,88,,167.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.72,33.11,,62.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.44,213.98,
COMPARTMENT PRESSURE COMPASS,491111,CDM,270,RC,,,Outpatient,,,238,142.8,,202.3,85,,161.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.47,80.03,,152.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.2,90,,171.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.44,88,,167.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.8,33.11,,63.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.52,214.2,
DEFIB/SHOCK/PACING,493760,CDM,270,RC,,,Outpatient,,,238,142.8,,202.3,85,,161.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.47,80.03,,152.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.2,90,,171.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.44,88,,167.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.8,33.11,,63.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.52,214.2,
CATHETER PERITONEAL 11FR,496969,CDM,270,RC,,,Outpatient,,,238,142.8,,202.3,85,,161.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.47,80.03,,152.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.2,90,,171.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.44,88,,167.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.8,33.11,,63.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.52,214.2,
EXTENDED RECOVERY ROOM,10011,CDM,710,RC,,,Outpatient,,,238,142.8,,202.3,85,,161.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.47,80.03,,152.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.2,90,,171.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.44,88,,167.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.8,33.11,,63.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.52,214.2,
OTHER RECOVERY ROOM,10012,CDM,719,RC,,,Outpatient,,,238,142.8,,202.3,85,,161.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.47,80.03,,152.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.2,90,,171.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.52,32.15,,61.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.44,88,,167.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.8,33.11,,63.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.52,214.2,
FACIAL BONES LESS THAN 3V,22268,CDM,320,RC,70140,HCPCS,Outpatient,,,239,143.4,,203.15,85,,162.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.27,80.03,,153.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,215.1,90,,172.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.32,88,,168.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.13,33.11,,63.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.84,215.1,
P/T APPLICATION OF UNNA BOOT,3906,CDM,420,RC,29580,HCPCS,Outpatient,,,239,143.4,,203.15,85,,162.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.27,80.03,,153.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,215.1,90,,172.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.32,88,,168.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.13,33.11,,63.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.84,215.1,
RECOVERY ROOM EMERGENCY CHARGE,10200,CDM,710,RC,,,Outpatient,,,239,143.4,,203.15,85,,162.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.27,80.03,,153.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,215.1,90,,172.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.84,32.15,,61.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.32,88,,168.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.13,33.11,,63.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.84,215.1,
"RISTOCETIN CO FACTOR, PLASMA (MAYO)",1885248,CDM,300,RC,85245,HCPCS,Outpatient,,,239.33,143.6,,203.43,85,,162.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,191.54,80.03,,153.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,215.4,90,,172.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,210.61,88,,168.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.85,215.4,
Use of EKG to monitor cardiac rehabilitation,398,CDM,943,RC,93798,HCPCS,Outpatient,,,239.44,143.66,,203.52,85,,162.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.98,32.15,,61.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.62,80.03,,153.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,115.11,102,,,fee schedule,Pays at 102% of CMS APC rate,215.5,90,,172.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.98,32.15,,61.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.11,100,,,fee schedule,Pays at 100% of CMS APC rate,76.98,32.15,,61.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.71,88,,168.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.28,33.11,,63.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.98,215.5,
ESOPHAGRAM,22083,CDM,320,RC,74230,HCPCS,Outpatient,,,239.45,143.67,,203.53,85,,162.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.98,32.15,,61.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.63,80.03,,153.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,215.51,90,,172.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.98,32.15,,61.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,76.98,32.15,,61.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.72,88,,168.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.28,33.11,,63.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.98,215.51,
"AMINO ACID, PLASMA, QT  (MAYO)",1882115,CDM,300,RC,82131,HCPCS,Outpatient,,,239.75,143.85,,203.79,85,,163.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,191.87,80.03,,153.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.43,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,215.78,90,,172.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.43,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,210.98,88,,168.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.21,215.78,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",22343,CDM,401,RC,77066,HCPCS,Outpatient,,,240,144,,204,85,,163.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.16,32.15,,61.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,192.07,80.03,,153.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,101.75,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,216,90,,172.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.16,32.15,,61.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.75,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,77.16,32.15,,61.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.2,88,,168.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.46,33.11,,63.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,77.16,216,
ZYVOX  (linezolid) 600MG /300ML PB,293451,CDM,636,RC,J2020,HCPCS,Outpatient,,,240,144,,204,85,,163.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,192.07,80.03,,153.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216,90,,172.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,211.2,88,,168.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.65,216,
ARIXTRA (fondaparinux) 5MG/0.4ML SC INJ,293864,CDM,636,RC,J1652,HCPCS,Outpatient,,,240.85,144.51,,204.72,85,,163.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.43,32.15,,61.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,192.75,80.03,,154.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.77,90,,173.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.43,32.15,,61.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.43,32.15,,61.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.95,88,,169.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.75,33.11,,63.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,77.43,216.77,
ARIXTRA (fondaparinux) 7.5MG/0.6ML SC,293866,CDM,636,RC,J1652,HCPCS,Outpatient,,,240.85,144.51,,204.72,85,,163.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.43,32.15,,61.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,192.75,80.03,,154.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.77,90,,173.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.43,32.15,,61.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.43,32.15,,61.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.95,88,,169.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.75,33.11,,63.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,77.43,216.77,
CORTISPORIN OTIC SUSP10ML,297805,CDM,250,RC,,,Outpatient,,,241.63,144.98,,205.39,85,,164.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.68,32.15,,62.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.38,80.03,,154.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,217.47,90,,173.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.68,32.15,,62.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.68,32.15,,62.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,212.63,88,,170.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80,33.11,,64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,77.68,217.47,
MECHANICAL THROMBECTOMY,22790,CDM,320,RC,36904,HCPCS,Outpatient,,,242,145.2,,205.7,85,,164.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.8,32.15,,62.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,193.67,80.03,,154.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5000.02,102,,,fee schedule,Pays at 102% of CMS APC rate,217.8,90,,174.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.8,32.15,,62.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5000.02,100,,,fee schedule,Pays at 100% of CMS APC rate,77.8,32.15,,62.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,212.96,88,,170.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.13,33.11,,64.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,77.8,217.8,
Radiologic examination of one side of the chest/ribs,22027,CDM,320,RC,71101,HCPCS,Outpatient,,,242.72,145.63,,206.31,85,,165.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.03,32.15,,62.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.25,80.03,,155.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,218.45,90,,174.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.03,32.15,,62.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,78.03,32.15,,62.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,213.59,88,,170.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.36,33.11,,64.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.03,218.45,
"Radiologic examination of the middle spine, 3 views",22266,CDM,320,RC,72072,HCPCS,Outpatient,,,242.72,145.63,,206.31,85,,165.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.03,32.15,,62.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.25,80.03,,155.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,218.45,90,,174.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.03,32.15,,62.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,78.03,32.15,,62.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,213.59,88,,170.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.36,33.11,,64.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.03,218.45,
O/T DRY WOUND,3917,CDM,430,RC,G0169,HCPCS,Outpatient,,,243.4,146.04,,206.89,85,,165.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.25,32.15,,62.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.79,80.03,,155.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.06,90,,175.25,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.25,32.15,,62.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.25,32.15,,62.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.19,88,,171.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.59,33.11,,64.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.25,219.06,
TUBE TRACH LO PRESSURE CUFFED #8,493841,CDM,270,RC,,,Outpatient,,,244,146.4,,207.4,85,,165.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.45,32.15,,62.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.27,80.03,,156.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.6,90,,175.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.45,32.15,,62.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.45,32.15,,62.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.72,88,,171.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.79,33.11,,64.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.45,219.6,
3A  ANDROSTANEDIOL G  (MAYO),1882154,CDM,300,RC,82154,HCPCS,Outpatient,,,244,146.4,,207.4,85,,165.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,195.27,80.03,,156.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,29.4,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,219.6,90,,175.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,29.4,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,36.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,214.72,88,,171.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.26,219.6,
"O/T WHFO,W/O JOINTS(PREFABRICATED)",3983,CDM,274,RC,L3807,HCPCS,Outpatient,,,244.25,146.55,,207.61,85,,166.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.53,32.15,,62.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.47,80.03,,156.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.83,90,,175.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.53,32.15,,62.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.53,32.15,,62.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.94,88,,171.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.87,33.11,,64.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.53,219.83,
FINGER JOINT JACK PREFAB,314105,CDM,274,RC,L3928,HCPCS,Outpatient,,,244.5,146.7,,207.83,85,,166.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.61,32.15,,62.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.67,80.03,,156.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.05,90,,176.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.61,32.15,,62.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.61,32.15,,62.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.16,88,,172.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.95,33.11,,64.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.61,220.05,
TRANSDUCER INTRAUTERINE 400,492111,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
TUBE TRACH W/OBTURATOR SZ3,493834,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
TUBE TRACH W/OBTURATOR SZ 3.5,493835,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
TUBE TRACH W/OBTURATOR SZ 4.0,493836,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
TUBE TRACH W/OBTURATOR #2,493837,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
TUBE TRACH W/OBTURATOR SZ 5,493838,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
TUBE TRACH W/OBTURATOR SZ 5.5,493839,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
TUBE TRACH CUFFED LOW PRESSURE SZ4,493848,CDM,270,RC,,,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
General health panel,1880009,CDM,300,RC,80050,HCPCS,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.85,32.15,,63.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.2,33.11,,64.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.85,220.73,
Blood test to assist with diagnosis,2188313,CDM,310,RC,88313,HCPCS,Outpatient,,,245.25,147.15,,208.46,85,,166.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,196.27,80.03,,157.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,220.73,90,,176.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,215.82,88,,172.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,220.73,
DDAVP (desmopressin) INTRANASAL 5ML,296082,CDM,250,RC,,,Outpatient,,,246.17,147.7,,209.24,85,,167.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.14,32.15,,63.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.01,80.03,,157.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.55,90,,177.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.14,32.15,,63.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.14,32.15,,63.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,216.63,88,,173.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.51,33.11,,65.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.14,221.55,
CABLE SURGICAL DISPOSABLE 301-CG,4999933,CDM,270,RC,,,Outpatient,,,246.75,148.05,,209.74,85,,167.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.33,32.15,,63.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.47,80.03,,157.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.08,90,,177.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.33,32.15,,63.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.33,32.15,,63.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.14,88,,173.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.7,33.11,,65.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.33,222.08,
KIT LEAD INTRODUCER 14GA  6,4999950,CDM,278,RC,C1894,HCPCS,Outpatient,,,247,148.2,,209.95,85,,167.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.41,32.15,,63.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.67,80.03,,158.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.3,90,,177.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.41,32.15,,63.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.41,32.15,,63.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.36,88,,173.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.78,33.11,,65.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.41,222.3,
O/T  HEAVY EXUDATE WOUNDS,448,CDM,430,RC,97799,HCPCS,Outpatient,,,247.6,148.56,,210.46,85,,168.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.6,32.15,,63.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.15,80.03,,158.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.84,90,,178.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.6,32.15,,63.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.6,32.15,,63.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.89,88,,174.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.98,33.11,,65.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.6,222.84,
"CoENZYME Q10, Co10  (MAYO)",1882493,CDM,300,RC,82542,HCPCS,Outpatient,,,247.75,148.65,,210.59,85,,168.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,198.27,80.03,,158.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,222.98,90,,178.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,218.02,88,,174.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,222.98,
PORT SACROILIAC JOINTS <3V,22241,CDM,320,RC,72200,HCPCS,Outpatient,,,248.5,149.1,,211.23,85,,168.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.87,80.03,,159.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,223.65,90,,178.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,218.68,88,,174.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.28,33.11,,65.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.89,223.65,
PORT SACRUM/COCCYX 2V,22242,CDM,320,RC,72220,HCPCS,Outpatient,,,248.5,149.1,,211.23,85,,168.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.87,80.03,,159.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,223.65,90,,178.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,218.68,88,,174.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.28,33.11,,65.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.89,223.65,
PORT SCAPULA,22243,CDM,320,RC,73010,HCPCS,Outpatient,,,248.5,149.1,,211.23,85,,168.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.87,80.03,,159.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,223.65,90,,178.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,79.89,32.15,,63.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,218.68,88,,174.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.28,33.11,,65.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.89,223.65,
BRACE D-RING WRIST,49551,CDM,274,RC,L3908,HCPCS,Outpatient,,,248.75,149.25,,211.44,85,,169.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.97,32.15,,63.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.07,80.03,,159.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.88,90,,179.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.97,32.15,,63.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.97,32.15,,63.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,218.9,88,,175.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.36,33.11,,65.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.97,223.88,
"PLA2R PARAFFIN IF, RENAL  (MAYO)",2188363,CDM,310,RC,88347,HCPCS,Outpatient,,,248.75,149.25,,211.44,85,,169.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.97,32.15,,63.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.07,80.03,,159.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.88,90,,179.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.97,32.15,,63.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.97,32.15,,63.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,218.9,88,,175.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.36,33.11,,65.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.97,223.88,
TRAY CATH FOLEY 16FR TEMPERATURE SENSING,49570,CDM,270,RC,,,Outpatient,,,249,149.4,,211.65,85,,169.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.05,32.15,,64.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.27,80.03,,159.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.1,90,,179.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.05,32.15,,64.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.05,32.15,,64.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,219.12,88,,175.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.44,33.11,,65.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,80.05,224.1,
PNEUMOCYSTIS JIROVECKI (CARINII) PCR,1887794,CDM,300,RC,87798,HCPCS,Outpatient,,,249,149.4,,211.65,85,,169.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,199.27,80.03,,159.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,224.1,90,,179.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,219.12,88,,175.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,224.1,
INTEGRILIN (EPTIFIBATIDE) 2MG/ML 10MLVIA,292118,CDM,636,RC,J1327,HCPCS,Outpatient,,,249,149.4,,211.65,85,,169.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.05,32.15,,64.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.27,80.03,,159.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.1,90,,179.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.05,32.15,,64.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.05,32.15,,64.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,219.12,88,,175.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.44,33.11,,65.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,80.05,224.1,
RENAL PATHOLOGY CONSULT  (MAYO),2188324,CDM,310,RC,88325,HCPCS,Outpatient,,,249.5,149.7,,212.08,85,,169.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,199.67,80.03,,159.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,224.55,90,,179.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,95.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,219.56,88,,175.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,95.02,224.55,
"DRAPE T, LAPAROTOMY 102  X 78  X 121",499221,CDM,270,RC,,,Outpatient,,,249.69,149.81,,212.24,85,,169.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.28,32.15,,64.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.83,80.03,,159.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.72,90,,179.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.28,32.15,,64.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.28,32.15,,64.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,219.73,88,,175.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.67,33.11,,66.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,80.28,224.72,
"LACTOFERRIN, FECAL (MAYO)",1884904,CDM,300,RC,83630,HCPCS,Outpatient,,,250,150,,212.5,85,,170,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,200.08,80.03,,160.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,225,90,,180,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,220,88,,176,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,225,
EBER (FISH PROBE)  (CSI),2188341,CDM,310,RC,88365,HCPCS,Outpatient,,,250.25,150.15,,212.71,85,,170.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,200.28,80.03,,160.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,225.23,90,,180.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,88.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,220.22,88,,176.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.18,225.23,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",22293,CDM,401,RC,77065,HCPCS,Outpatient,,,250.63,150.38,,213.04,85,,170.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.58,32.15,,64.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,200.58,80.03,,160.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.83,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,225.57,90,,180.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.58,32.15,,64.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.83,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,80.58,32.15,,64.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.55,88,,176.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.98,33.11,,66.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,80.58,225.57,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",22342,CDM,401,RC,77065,HCPCS,Outpatient,,,250.63,150.38,,213.04,85,,170.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.58,32.15,,64.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,200.58,80.03,,160.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.83,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,225.57,90,,180.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.58,32.15,,64.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.83,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,80.58,32.15,,64.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.55,88,,176.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,82.98,33.11,,66.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,80.58,225.57,
ANALYSIS OF NEUROSTIM PULSE GENERATOR,9061,CDM,920,RC,95972,HCPCS,Outpatient,,,251.5,150.9,,213.78,85,,171.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.86,32.15,,64.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,201.28,80.03,,161.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,95.67,102,,,fee schedule,Pays at 102% of CMS APC rate,226.35,90,,181.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.86,32.15,,64.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.67,100,,,fee schedule,Pays at 100% of CMS APC rate,80.86,32.15,,64.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,221.32,88,,177.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.27,33.11,,66.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,80.86,226.35,
TUBE TRACH LO PRESSURE CUFFED #6,493840,CDM,270,RC,,,Outpatient,,,252.5,151.5,,214.63,85,,171.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.18,32.15,,64.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.08,80.03,,161.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.25,90,,181.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.18,32.15,,64.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,81.18,32.15,,64.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,222.2,88,,177.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.6,33.11,,66.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.18,227.25,
TUBE TRACH LO PRESSURE CUFFED #10,493842,CDM,270,RC,,,Outpatient,,,252.5,151.5,,214.63,85,,171.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.18,32.15,,64.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.08,80.03,,161.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.25,90,,181.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.18,32.15,,64.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,81.18,32.15,,64.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,222.2,88,,177.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.6,33.11,,66.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.18,227.25,
O/T EVAL MOD COMPLEXITY,5997166,CDM,434,RC,97166,HCPCS,Outpatient,,,252.97,151.78,,215.02,85,,172.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.33,32.15,,65.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.45,80.03,,161.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,97.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,227.67,90,,182.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.33,32.15,,65.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,81.33,32.15,,65.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,222.61,88,,178.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.76,33.11,,67.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.33,227.67,
O/T EVAL HIGH COMPLEXITY,5997167,CDM,434,RC,97167,HCPCS,Outpatient,,,252.97,151.78,,215.02,85,,172.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.33,32.15,,65.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,202.45,80.03,,161.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,97.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,227.67,90,,182.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.33,32.15,,65.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,81.33,32.15,,65.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,222.61,88,,178.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.76,33.11,,67.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.33,227.67,
"AMNISURE, PAMG-1",1889010,CDM,300,RC,84112,HCPCS,Outpatient,,,253.5,152.1,,215.48,85,,172.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,202.88,80.03,,162.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,100.07,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,228.15,90,,182.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,100.07,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,72.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,223.08,88,,178.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,72.51,228.15,
BAYRHO 300MCG INJ,293822,CDM,250,RC,,,Outpatient,,,254,152.4,,215.9,85,,172.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.66,32.15,,65.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.28,80.03,,162.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228.6,90,,182.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.66,32.15,,65.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,81.66,32.15,,65.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.52,88,,178.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.1,33.11,,67.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.66,228.6,
Therapy for speech or hearing,322007,CDM,440,RC,92507,HCPCS,Outpatient,,,254.38,152.63,,216.22,85,,172.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.78,32.15,,65.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.58,80.03,,162.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,228.94,90,,183.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.78,32.15,,65.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,81.78,32.15,,65.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.85,88,,179.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.23,33.11,,67.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.78,228.94,
O/T CMC THUMB BRACE,3951,CDM,274,RC,L3807,HCPCS,Outpatient,,,254.5,152.7,,216.33,85,,173.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.68,80.03,,162.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.05,90,,183.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.96,88,,179.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.26,33.11,,67.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.82,229.05,
DO NOT USE,322021,CDM,440,RC,92506,HCPCS,Outpatient,,,254.5,152.7,,216.33,85,,173.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.68,80.03,,162.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.05,90,,183.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.96,88,,179.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.26,33.11,,67.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.82,229.05,
"Radiologic examination of the middle spine, 3 views",22047,CDM,320,RC,72072,HCPCS,Outpatient,,,254.75,152.85,,216.54,85,,173.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.9,32.15,,65.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.88,80.03,,163.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,229.28,90,,183.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.9,32.15,,65.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,81.9,32.15,,65.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.18,88,,179.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.35,33.11,,67.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.9,229.28,
"ARBOVIRUS/WEST NILE AB PANEL,CSF  (MAYO)",1886652,CDM,300,RC,,,Outpatient,,,255.2,153.12,,216.92,85,,173.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,82.05,32.15,,65.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.24,80.03,,163.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.68,90,,183.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,82.05,32.15,,65.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.05,32.15,,65.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.58,88,,179.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.5,33.11,,67.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,82.05,229.68,
THAMSOLN : 500ML,296350,CDM,258,RC,,,Outpatient,,,255.96,153.58,,217.57,85,,174.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,82.29,32.15,,65.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.84,80.03,,163.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.36,90,,184.29,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,82.29,32.15,,65.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.29,32.15,,65.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,225.24,88,,180.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.75,33.11,,67.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,82.29,230.36,
MONOTORING TUBING,49102,CDM,270,RC,,,Outpatient,,,256.25,153.75,,217.81,85,,174.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,82.38,32.15,,65.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.08,80.03,,164.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.63,90,,184.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,82.38,32.15,,65.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.38,32.15,,65.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,225.5,88,,180.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.84,33.11,,67.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,82.38,230.63,
IRRADIATED BLOOD PROD,2086342,CDM,390,RC,86945,HCPCS,Outpatient,,,256.5,153.9,,218.03,85,,174.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,205.28,80.03,,164.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,230.85,90,,184.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,36.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,225.72,88,,180.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.05,230.85,
"DIHYDROSETOSTERONE, SERUM  (MAYO)",1882000,CDM,300,RC,80327,HCPCS,Outpatient,,,256.75,154.05,,218.24,85,,174.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,205.48,80.03,,164.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.08,90,,184.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,32.46,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,225.94,88,,180.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.46,231.08,
HUMERUS BILATERAL 2 VIEWS,22381,CDM,320,RC,73060,HCPCS,Outpatient,,,256.75,154.05,,218.24,85,,174.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,82.55,32.15,,66.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.48,80.03,,164.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,231.08,90,,184.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,82.55,32.15,,66.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,82.55,32.15,,66.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,225.94,88,,180.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.01,33.11,,68.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,82.55,231.08,
NM DISOFENIN,2932286,CDM,343,RC,A9510,HCPCS,Outpatient,,,257.2,154.32,,218.62,85,,174.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,82.69,32.15,,66.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.84,80.03,,164.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.48,90,,185.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,82.69,32.15,,66.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.69,32.15,,66.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,226.34,88,,181.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.16,33.11,,68.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,82.69,231.48,
"H. PYLORI, FECES AG, EIA (MAYO)",1887338,CDM,300,RC,87338,HCPCS,Outpatient,,,257.25,154.35,,218.66,85,,174.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,205.88,80.03,,164.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,231.53,90,,185.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,18.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,226.38,88,,181.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.63,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.09,231.53,
HE4 OVARIAN CANCER MARKER  (MAYO),1886318,CDM,300,RC,86316,HCPCS,Outpatient,,,258.5,155.1,,219.73,85,,175.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,206.88,80.03,,165.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.22,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,232.65,90,,186.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,227.48,88,,181.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.16,232.65,
Urine test,2188173,CDM,310,RC,88112,HCPCS,Outpatient,,,258.5,155.1,,219.73,85,,175.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,206.88,80.03,,165.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,232.65,90,,186.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,227.48,88,,181.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,106.19,232.65,
CONSULT DURING SURGERY,2188329,CDM,310,RC,88329,HCPCS,Outpatient,,,258.5,155.1,,219.73,85,,175.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,206.88,80.03,,165.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,232.65,90,,186.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,36.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,227.48,88,,181.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.98,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,36.87,232.65,
PORT STERNOCLAVICULAR JOINTS 3V,22253,CDM,320,RC,71130,HCPCS,Outpatient,,,258.5,155.1,,219.73,85,,175.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.88,80.03,,165.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,232.65,90,,186.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.48,88,,181.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.59,33.11,,68.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.11,232.65,
EMERGENCY AFTER HOURS SURGERY,11015,CDM,360,RC,,,Outpatient,,,258.5,155.1,,219.73,85,,175.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.88,80.03,,165.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.65,90,,186.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.48,88,,181.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.59,33.11,,68.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.11,232.65,
PORT US BREAST ECHOGRAPHY UNIL,24037,CDM,402,RC,76641,HCPCS,Outpatient,,,258.5,155.1,,219.73,85,,175.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.88,80.03,,165.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,232.65,90,,186.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.48,88,,181.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.59,33.11,,68.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.11,232.65,
"PILONIOAL CYST, SIMPLE",1410089,CDM,450,RC,,,Outpatient,,,258.5,155.1,,219.73,85,,175.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.88,80.03,,165.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.65,90,,186.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.11,32.15,,66.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.48,88,,181.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.59,33.11,,68.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.11,232.65,
S/T FEEDING/SWALLOWING EVAL 45-Min,3220022,CDM,440,RC,92610,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,68.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
S/T FEEDING/SWALLOWING EVAL 60-Min,3220023,CDM,440,RC,92610,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,68.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
APPLY HAND/WRIST CAST (GUANTLET),1429085,CDM,450,RC,29085,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
STRAPPING; ANKLE,1429540,CDM,450,RC,29540,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
STRAPPING; UNNA BOOT,1429580,CDM,450,RC,29580,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
REPAIR SPICA BODY CAST OR JACKET,1429720,CDM,450,RC,29720,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
WINDOWING OF CAST,1429730,CDM,450,RC,29730,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
NM CCK SINCALIDE,23055,CDM,636,RC,J2805,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.19,32.15,,66.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.67,33.11,,68.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.19,232.88,
STONE  QL ANALYSIS,1884106,CDM,300,RC,82355,HCPCS,Outpatient,,,260.5,156.3,,221.43,85,,177.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,208.48,80.03,,166.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,234.45,90,,187.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,229.24,88,,183.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.55,234.45,
FACTOR V ASSAY  (MAYO),1885211,CDM,300,RC,85220,HCPCS,Outpatient,,,260.5,156.3,,221.43,85,,177.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,208.48,80.03,,166.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,234.45,90,,187.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,229.24,88,,183.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.19,234.45,
1ST/UNIT/XM/TYPE/RH/ABS,2086068,CDM,391,RC,86063,HCPCS,Outpatient,,,260.5,156.3,,221.43,85,,177.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,208.48,80.03,,166.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,5.88,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,234.45,90,,187.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5.88,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,229.24,88,,183.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.26,234.45,
CLSD TX RIB FRACTURE EA UNCOMPLICATED,1421800,CDM,450,RC,,,Outpatient,,,261.25,156.75,,222.06,85,,177.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.99,32.15,,67.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.08,80.03,,167.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,235.13,90,,188.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.99,32.15,,67.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.99,32.15,,67.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.9,88,,183.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,86.5,33.11,,69.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.99,235.13,
CLSD TX OF VERTEBRAL ROCESS FX,1422305,CDM,450,RC,,,Outpatient,,,261.25,156.75,,222.06,85,,177.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.99,32.15,,67.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,209.08,80.03,,167.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,235.13,90,,188.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.99,32.15,,67.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.99,32.15,,67.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.9,88,,183.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,86.5,33.11,,69.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.99,235.13,
"CEA, PERITONEAL FLUID  (MAYO)",1884887,CDM,300,RC,82378,HCPCS,Outpatient,,,261.66,157,,222.41,85,,177.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,209.41,80.03,,167.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,235.49,90,,188.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,230.26,88,,184.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.86,235.49,
INSULIN-LIKE GROWTH FACTOR II (MAYO),1884898,CDM,300,RC,83519,HCPCS,Outpatient,,,262.25,157.35,,222.91,85,,178.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,209.88,80.03,,167.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,236.03,90,,188.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,230.78,88,,184.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,236.03,
BILE ACIDS-FRACTIONATED & TOTAL ( MAYO),1883789,CDM,300,RC,82542,HCPCS,Outpatient,,,262.5,157.5,,223.13,85,,178.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,210.08,80.03,,168.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,236.25,90,,189,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,231,88,,184.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,236.25,
MONUROL (FOSFOMYCIN) 3G PACKET,302623,CDM,250,RC,,,Outpatient,,,262.85,157.71,,223.42,85,,178.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,84.51,32.15,,67.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.36,80.03,,168.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.57,90,,189.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,84.51,32.15,,67.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,84.51,32.15,,67.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.31,88,,185.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.03,33.11,,69.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.51,236.57,
DO NOT USE,322026,CDM,440,RC,92510,HCPCS,Outpatient,,,263.25,157.95,,223.76,85,,179.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,84.63,32.15,,67.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.68,80.03,,168.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.93,90,,189.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,84.63,32.15,,67.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,84.63,32.15,,67.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.66,88,,185.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.16,33.11,,69.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.63,236.93,
INFUSION THERAPY OTHER THAN CHEMO,14350,CDM,450,RC,Q0081,HCPCS,Outpatient,,,263.75,158.25,,224.19,85,,179.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,84.8,32.15,,67.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.08,80.03,,168.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.38,90,,189.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,84.8,32.15,,67.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,84.8,32.15,,67.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.1,88,,185.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.33,33.11,,69.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.8,237.38,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",3970,CDM,420,RC,97597,HCPCS,Outpatient,,,264.06,158.44,,224.45,85,,179.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,84.9,32.15,,67.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.33,80.03,,169.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,237.65,90,,190.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,84.9,32.15,,67.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,84.9,32.15,,67.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.37,88,,185.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.43,33.11,,69.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.9,237.65,
P/T EVAL DO NOT USE AFTER 12/2016,313,CDM,424,RC,97001,HCPCS,Outpatient,,,264.5,158.7,,224.83,85,,179.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.04,32.15,,68.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.68,80.03,,169.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.05,90,,190.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.04,32.15,,68.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,85.04,32.15,,68.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.76,88,,186.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.58,33.11,,70.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.04,238.05,
O/T EVAL DO NOT USE AFTER 12/2106,3131,CDM,434,RC,97003,HCPCS,Outpatient,,,264.5,158.7,,224.83,85,,179.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.04,32.15,,68.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.68,80.03,,169.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.05,90,,190.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.04,32.15,,68.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.5,,,,Other,Not Separately reimbursable,85.04,32.15,,68.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.76,88,,186.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.58,33.11,,70.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.04,238.05,
LEVEL 2 ED VISIT,14006,CDM,450,RC,99282,HCPCS,Outpatient,,,264.86,158.92,,225.13,85,,180.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.97,80.03,,169.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,133.91,102,,,fee schedule,Pays at 102% of CMS APC rate,238.37,90,,190.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,133.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.08,88,,186.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,211.97,385,
LEVEL 2 WITH PROCEDURE,14017,CDM,450,RC,99282,HCPCS,Outpatient,,,264.86,158.92,,225.13,85,,180.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.97,80.03,,169.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,133.91,102,,,fee schedule,Pays at 102% of CMS APC rate,238.37,90,,190.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,133.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.08,88,,186.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,211.97,385,
S/T EVAL FOR VOICE PROSTHETIC DEVICE,322015,CDM,440,RC,92597,HCPCS,Outpatient,,,266.25,159.75,,226.31,85,,181.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.6,32.15,,68.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,213.08,80.03,,170.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,70.53,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,239.63,90,,191.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.6,32.15,,68.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.53,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,85.6,32.15,,68.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.3,88,,187.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.16,33.11,,70.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.6,239.63,
S/T SWALLOWING TREATMENT,322017,CDM,440,RC,92526,HCPCS,Outpatient,,,266.88,160.13,,226.85,85,,181.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.8,32.15,,68.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,213.58,80.03,,170.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,82.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,240.19,90,,192.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.8,32.15,,68.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,85.8,32.15,,68.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.85,88,,187.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.36,33.11,,70.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.8,240.19,
CATHETER INSERTION,1453670,CDM,450,RC,51702,HCPCS,Outpatient,,,267.32,160.39,,227.22,85,,181.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.94,32.15,,68.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,213.94,80.03,,171.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,240.59,90,,192.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.94,32.15,,68.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,85.94,32.15,,68.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.24,88,,188.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.51,33.11,,70.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.94,240.59,
"STREPTOKINASE: 250,000U INJ",293322,CDM,636,RC,J2995,HCPCS,Outpatient,,,267.5,160.5,,227.38,85,,181.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86,32.15,,68.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.08,80.03,,171.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.75,90,,192.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86,32.15,,68.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,267.5,,,,Other,Not Separately reimbursable,86,32.15,,68.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.4,88,,188.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.57,33.11,,70.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86,240.75,
"PATHOLOGY, CONSULT ON REFERRED SLIDES",2188322,CDM,310,RC,88321,HCPCS,Outpatient,,,267.75,160.65,,227.59,85,,182.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,214.28,80.03,,171.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,240.98,90,,192.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,59.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,235.62,88,,188.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,59.02,240.98,
VAC 1000 ml ATS CANISTER,43821,CDM,270,RC,,,Outpatient,,,268,160.8,,227.8,85,,182.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.48,80.03,,171.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.2,90,,192.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268,,,,Other,Not Separately reimbursable,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.84,88,,188.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.73,33.11,,70.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.16,241.2,
PARING OR CUTTING BENIGN HYPER LESION,11056,CDM,761,RC,11055,HCPCS,Outpatient,,,268,160.8,,227.8,85,,182.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.48,80.03,,171.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,241.2,90,,192.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.84,88,,188.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.73,33.11,,70.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.16,241.2,
MUSCLE CYTOCHROME OXIDASE STAIN (MAYO),2188377,CDM,300,RC,88319,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,86.63,242.1,
MUSCLE SUCCINIC DEHYDRO STAIN (MAYO),2188378,CDM,300,RC,88319,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,86.63,242.1,
MUSCLE ACETATE NON-SPEC EST STAIN (MAYO),2188380,CDM,300,RC,88319,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,86.63,242.1,
MUSCLE NADH DEHYDRO STAIN (MAYO),2188381,CDM,300,RC,88319,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,86.63,242.1,
MUSCLE ACID PHOSPHATASE STAIN (MAYO),2188385,CDM,300,RC,88319,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,86.63,242.1,
MUSCLE PHOSPHORYLASE STAIN (MAYO),2188386,CDM,300,RC,88319,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,86.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.23,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,86.63,242.1,
KIT TRANSDUCER PLUS/DTX DISPOSABLE,498501,CDM,270,RC,,,Outpatient,,,269.25,161.55,,228.86,85,,183.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.56,32.15,,69.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.48,80.03,,172.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.33,90,,193.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.56,32.15,,69.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,86.56,32.15,,69.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.94,88,,189.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.15,33.11,,71.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.56,242.33,
SYSTEM DELIVERY INJECTATE CLOSED,496380,CDM,270,RC,,,Outpatient,,,269.75,161.85,,229.29,85,,183.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.88,80.03,,172.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.78,90,,194.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.38,88,,189.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.31,33.11,,71.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.72,242.78,
BONE MARROW PREP & STAIN,2185109,CDM,310,RC,85097,HCPCS,Outpatient,,,269.75,161.85,,229.29,85,,183.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,215.88,80.03,,172.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,242.78,90,,194.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,,,,,Other,Not Separately reimbursable,237.38,88,,189.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,215.88,242.78,
BONE AGE HAND AP,22117,CDM,320,RC,77072,HCPCS,Outpatient,,,269.75,161.85,,229.29,85,,183.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.88,80.03,,172.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,242.78,90,,194.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.38,88,,189.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.31,33.11,,71.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.72,242.78,
FLUORO NEPHROSTOGRAM,22400,CDM,320,RC,74425,HCPCS,Outpatient,,,269.75,161.85,,229.29,85,,183.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.88,80.03,,172.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,242.78,90,,194.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.38,88,,189.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.31,33.11,,71.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.72,242.78,
NM TREADMILL (ONLY),2393015,CDM,482,RC,93017,HCPCS,Outpatient,,,269.75,161.85,,229.29,85,,183.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.88,80.03,,172.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.49,102,,,fee schedule,Pays at 102% of CMS APC rate,242.78,90,,194.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.49,100,,,fee schedule,Pays at 100% of CMS APC rate,86.72,32.15,,69.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.38,88,,189.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.31,33.11,,71.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.72,242.78,
OR  PYELOGRAM RETRO,22099,CDM,320,RC,74420,HCPCS,Outpatient,,,270.15,162.09,,229.63,85,,183.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.85,32.15,,69.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,216.2,80.03,,172.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,243.14,90,,194.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.85,32.15,,69.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,86.85,32.15,,69.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.73,88,,190.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.45,33.11,,71.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.85,243.14,
"C-ANCA, ANTINEUT CYTOPLASMIC ABS  (MAYO)",1886001,CDM,300,RC,86255,HCPCS,Outpatient,,,270.58,162.35,,229.99,85,,183.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,216.55,80.03,,173.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,243.52,90,,194.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,238.11,88,,190.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,243.52,
CUSTOM DYNAMIC SPLINT,593003,CDM,270,RC,,,Outpatient,,,271.7,163.02,,230.95,85,,184.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.44,80.03,,173.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,90,,195.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.1,88,,191.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.96,33.11,,71.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.35,244.53,
O/T CUSTOM SPLINT,593004,CDM,270,RC,,,Outpatient,,,271.7,163.02,,230.95,85,,184.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.44,80.03,,173.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,90,,195.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.1,88,,191.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.96,33.11,,71.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.35,244.53,
O/T ADULT NEURO EVALUATION,593023,CDM,430,RC,97750,HCPCS,Outpatient,,,271.7,163.02,,230.95,85,,184.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.44,80.03,,173.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.65,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,244.53,90,,195.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.65,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,87.35,32.15,,69.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.1,88,,191.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.96,33.11,,71.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.35,244.53,
OMNIPAQUE 350MG/ML (100ML),229967,CDM,255,RC,Q9967,HCPCS,Outpatient,,,271.75,163.05,,230.99,85,,184.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.37,32.15,,69.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.48,80.03,,173.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.58,90,,195.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.37,32.15,,69.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.37,32.15,,69.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.14,88,,191.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.98,33.11,,71.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.37,244.58,
FACET FLUORO GUIDE W NEEDLE PLCMT,22303,CDM,320,RC,77003,HCPCS,Outpatient,,,271.75,163.05,,230.99,85,,184.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.37,32.15,,69.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.48,80.03,,173.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.58,90,,195.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.37,32.15,,69.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.37,32.15,,69.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.14,88,,191.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.98,33.11,,71.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.37,244.58,
RABIES TITER  (MAYO),1886383,CDM,300,RC,86382,HCPCS,Outpatient,,,271.83,163.1,,231.06,85,,184.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,217.55,80.03,,174.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,244.65,90,,195.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.26,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,239.21,88,,191.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.9,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.26,244.65,
PURAPLY AM PER 1 SQ CM,844196,CDM,278,RC,Q4196,HCPCS,Outpatient,,,271.9,163.14,,231.12,85,,184.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.42,32.15,,69.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.6,80.03,,174.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.71,90,,195.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.42,32.15,,69.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.42,32.15,,69.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.27,88,,191.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.03,33.11,,72.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.42,244.71,
HIV-1 RNA/PCR  (MAYO),1883890,CDM,300,RC,87536,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,86.8,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.8,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,56.5,245.03,
PTT-LA CONFIRMATION  (MAYO),1885597,CDM,300,RC,85597,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.61,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.61,245.03,
ABO BLOOD TYPING,2086081,CDM,300,RC,86900,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,3.75,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.75,245.03,
INITIAL CPT/POSTURAL DRAINAGE,30025,CDM,410,RC,94667,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
O/T FINGER SPLINT WITH OUTRIGGER,3938,CDM,430,RC,L3920,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
INTRANASAL-REMOVE F B,1430300,CDM,450,RC,30300,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
CONTRL ANT/NASL HEMORR,1430901,CDM,450,RC,30901,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
INSERT NON INDWELLING (STRAIGHT) CATH,1451701,CDM,450,RC,51701,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
REMOVAL FB-EAR,1469200,CDM,450,RC,69200,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
INSERT NON INDWELLING BLADDER CATH,1151701,CDM,761,RC,51701,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
THERAPEUTIC PHLEBOTOMY,2086999,CDM,940,RC,99195,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
"NBT, NITROBLUE TETRAZOLIUM  (MAYO)",1882561,CDM,300,RC,82600,HCPCS,Outpatient,,,272.5,163.5,,231.63,85,,185.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,218.08,80.03,,174.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,245.25,90,,196.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,239.8,88,,191.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.4,245.25,
PREMARIN (CONJ ESTROGEN) IV: 25MG,296050,CDM,636,RC,J1410,HCPCS,Outpatient,,,273,163.8,,232.05,85,,185.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,372.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,218.48,80.03,,174.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,379.92,102,,,fee schedule,Pays at 102% of CMS APC rate,245.7,90,,196.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,372.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,379.92,100,,,fee schedule,Pays at 100% of CMS APC rate,372.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,240.24,88,,192.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,383.65,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,218.48,372.48,
CULTURE REF ID MYCOBACTERIA/NOCAR (MAYO),1887188,CDM,300,RC,87118,HCPCS,Outpatient,,,273.5,164.1,,232.48,85,,185.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.93,32.15,,70.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,218.88,80.03,,175.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,246.15,90,,196.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.93,32.15,,70.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,87.93,32.15,,70.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.68,88,,192.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.56,33.11,,72.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.93,246.15,
TUBE TRACH FENESTRATED CUFFED #6,493844,CDM,270,RC,,,Outpatient,,,273.75,164.25,,232.69,85,,186.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.01,32.15,,70.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,219.08,80.03,,175.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.38,90,,197.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.01,32.15,,70.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,88.01,32.15,,70.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.9,88,,192.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.64,33.11,,72.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,88.01,246.38,
VON WILLEBRAND FACTOR ACTIVITY  (MAYO),1885249,CDM,300,RC,85397,HCPCS,Outpatient,,,274.12,164.47,,233,85,,186.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,219.38,80.03,,175.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,31.47,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,246.71,90,,197.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,31.47,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,241.23,88,,192.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.81,246.71,
LUMIGAN (bimatoprost) OPTH SOL 0.01%2.5,291035,CDM,250,RC,,,Outpatient,,,275,165,,233.75,85,,187,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.41,32.15,,70.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.08,80.03,,176.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247.5,90,,198,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.41,32.15,,70.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,88.41,32.15,,70.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,242,88,,193.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.05,33.11,,72.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,88.41,247.5,
IV THERAPY HYDRATION INIT HOUR,290082,CDM,260,RC,96360,HCPCS,Outpatient,,,275,165,,233.75,85,,187,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.41,32.15,,70.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.08,80.03,,176.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,247.5,90,,198,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.41,32.15,,70.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,88.41,32.15,,70.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,242,88,,193.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.05,33.11,,72.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,88.41,247.5,
"EPOGEN *NON DIALYSIS* 10,000UNIT INJ",293499,CDM,636,RC,J0885,HCPCS,Outpatient,,,275,165,,233.75,85,,187,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,220.08,80.03,,176.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.23,102,,,fee schedule,Pays at 102% of CMS APC rate,247.5,90,,198,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.23,100,,,fee schedule,Pays at 100% of CMS APC rate,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,242,88,,193.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.09,247.5,
meningococcal Meningococcal conjugate vaccine,296057,CDM,636,RC,90734,HCPCS,Outpatient,,,275,165,,233.75,85,,187,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,148.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,220.08,80.03,,176.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247.5,90,,198,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,148.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,148.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,242,88,,193.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,152.94,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,148.49,247.5,
Therapy for speech or hearing,322008,CDM,440,RC,92507,HCPCS,Outpatient,,,275.25,165.15,,233.96,85,,187.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.49,32.15,,70.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.28,80.03,,176.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,247.73,90,,198.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.49,32.15,,70.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,88.49,32.15,,70.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,242.22,88,,193.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.14,33.11,,72.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,88.49,247.73,
TUBE TRACH FENESTRATED CUFFED #8,493845,CDM,270,RC,,,Outpatient,,,275.5,165.3,,234.18,85,,187.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.57,32.15,,70.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.48,80.03,,176.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247.95,90,,198.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.57,32.15,,70.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,88.57,32.15,,70.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,242.44,88,,193.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.22,33.11,,72.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,88.57,247.95,
"PLASMINOGEN ACTIVATOR, PAI-1  (MAYO)",1885415,CDM,300,RC,83520,HCPCS,Outpatient,,,276.25,165.75,,234.81,85,,187.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,221.08,80.03,,176.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,248.63,90,,198.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,243.1,88,,194.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,248.63,
PLATELET AB  (MAYO),1886022,CDM,300,RC,86022,HCPCS,Outpatient,,,277.25,166.35,,235.66,85,,188.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,221.88,80.03,,177.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,249.53,90,,199.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,243.98,88,,195.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.09,249.53,
REMOVAL OF DEVITALIZED TISSUE,97602,CDM,761,RC,97602,HCPCS,Outpatient,,,277.25,166.35,,235.66,85,,188.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.14,32.15,,71.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,221.88,80.03,,177.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,249.53,90,,199.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.14,32.15,,71.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,89.14,32.15,,71.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,243.98,88,,195.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.8,33.11,,73.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.14,249.53,
SIMPLE REPAIR - TRUNK - 7.6-12.5 CM,8412004,CDM,761,RC,12004,HCPCS,Outpatient,,,277.25,166.35,,235.66,85,,188.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.14,32.15,,71.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,221.88,80.03,,177.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,249.53,90,,199.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.14,32.15,,71.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,89.14,32.15,,71.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,243.98,88,,195.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.8,33.11,,73.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.14,249.53,
ANTI-GAD 65/INSULIN I125  (MAYO),1886334,CDM,300,RC,86341,HCPCS,Outpatient,,,278.75,167.25,,236.94,85,,189.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,223.08,80.03,,178.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,250.88,90,,200.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,245.3,88,,196.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.89,250.88,
BCR/ABL1 (t(9;22)) TRANS; MAJOR  (MAYO),1886135,CDM,310,RC,81206,HCPCS,Outpatient,,,278.98,167.39,,237.13,85,,189.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,223.27,80.03,,178.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,167.23,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,251.08,90,,200.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,167.23,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,245.5,88,,196.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,98.4,251.08,
BCR/ABL1 (t(9;22)) TRANS; MINOR  (MAYO),1886138,CDM,310,RC,81207,HCPCS,Outpatient,,,278.98,167.39,,237.13,85,,189.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,223.27,80.03,,178.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,147.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,251.08,90,,200.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,147.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,245.5,88,,196.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,98.4,251.08,
BCR/ABL1 (t(9;22)) TRANS; OTHER  (MAYO),1886139,CDM,310,RC,81208,HCPCS,Outpatient,,,278.98,167.39,,237.13,85,,189.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,223.27,80.03,,178.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,218.91,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,251.08,90,,200.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,218.91,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,245.5,88,,196.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,98.4,251.08,
TUBE TRACH FENESTRATED CUFFED #4,493843,CDM,270,RC,,,Outpatient,,,279,167.4,,237.15,85,,189.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.7,32.15,,71.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.28,80.03,,178.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.1,90,,200.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.7,32.15,,71.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,89.7,32.15,,71.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.52,88,,196.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.38,33.11,,73.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.7,251.1,
HEPATITIS C VIRUS (HCV-RNA)  (MAYO),1886290,CDM,300,RC,87522,HCPCS,Outpatient,,,279,167.4,,237.15,85,,189.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,223.28,80.03,,178.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,43.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,251.1,90,,200.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,245.52,88,,196.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,53.87,251.1,
SIALOGRAM,22019,CDM,320,RC,70390,HCPCS,Outpatient,,,279,167.4,,237.15,85,,189.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.7,32.15,,71.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.28,80.03,,178.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,251.1,90,,200.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.7,32.15,,71.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,89.7,32.15,,71.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.52,88,,196.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.38,33.11,,73.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.7,251.1,
PORT A-C JOINTS,22201,CDM,320,RC,73050,HCPCS,Outpatient,,,279.25,167.55,,237.36,85,,189.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.48,80.03,,178.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,251.33,90,,201.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.74,88,,196.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.46,33.11,,73.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.78,251.33,
Ultrasound of fetus with limited views,24017,CDM,402,RC,76815,HCPCS,Outpatient,,,279.25,167.55,,237.36,85,,189.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.48,80.03,,178.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,251.33,90,,201.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.74,88,,196.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.46,33.11,,73.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.78,251.33,
Limited ultrasound of the pelvis,24019,CDM,402,RC,76857,HCPCS,Outpatient,,,279.25,167.55,,237.36,85,,189.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.48,80.03,,178.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,251.33,90,,201.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,89.78,32.15,,71.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.74,88,,196.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.46,33.11,,73.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.78,251.33,
"LAXATIVE ASSAY, STOOL  (MAYO)",1883734,CDM,300,RC,83735,HCPCS,Outpatient,,,279.5,167.7,,237.58,85,,190.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,223.68,80.03,,178.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,251.55,90,,201.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,245.96,88,,196.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.42,251.55,
Therapy for speech or hearing,322012,CDM,440,RC,92507,HCPCS,Outpatient,,,279.5,167.7,,237.58,85,,190.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.86,32.15,,71.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.68,80.03,,178.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,251.55,90,,201.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.86,32.15,,71.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,89.86,32.15,,71.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.96,88,,196.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.54,33.11,,74.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.86,251.55,
HLA  A & B CLASS I DNA TYPING  (MAYO),1886813,CDM,300,RC,86813,HCPCS,Outpatient,,,280.25,168.15,,238.21,85,,190.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,224.28,80.03,,179.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,59.16,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,252.23,90,,201.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,59.16,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,72.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,246.62,88,,197.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,72.92,252.23,
TAUT INTRODUCER 3.5  CHOLANGIOGRAPHY,4999019,CDM,270,RC,,,Outpatient,,,281,168.6,,238.85,85,,191.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,90.34,32.15,,72.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.88,80.03,,179.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.9,90,,202.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,90.34,32.15,,72.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,90.34,32.15,,72.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.28,88,,197.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,93.04,33.11,,74.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,90.34,252.9,
LEFLUNOMIDE (TERIFLUNOMIDE)  (MAYO),1880304,CDM,300,RC,80299,HCPCS,Outpatient,,,281.5,168.9,,239.28,85,,191.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,225.28,80.03,,180.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,253.35,90,,202.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.14,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,247.72,88,,198.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.14,253.35,
"CHOLESTEROL, BF  (MAYO)",1883709,CDM,300,RC,84311,HCPCS,Outpatient,,,281.5,168.9,,239.28,85,,191.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,225.28,80.03,,180.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.26,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,253.35,90,,202.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.26,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,8.79,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,247.72,88,,198.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.05,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,8.79,253.35,
ARCH KOH-EFFICIENT 4.0CM,499996,CDM,270,RC,,,Outpatient,,,282.75,169.65,,240.34,85,,192.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,90.9,32.15,,72.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,226.28,80.03,,181.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.48,90,,203.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,90.9,32.15,,72.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,90.9,32.15,,72.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,248.82,88,,199.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,93.62,33.11,,74.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,90.9,254.48,
APPLICATION SKIN SUB GRAFT/ARM/LEG EA AD,15272,CDM,761,RC,15272,HCPCS,Outpatient,,,282.75,169.65,,240.34,85,,192.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,90.9,32.15,,72.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,226.28,80.03,,181.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.48,90,,203.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,90.9,32.15,,72.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,90.9,32.15,,72.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,248.82,88,,199.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,93.62,33.11,,74.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,90.9,254.48,
O/T FLEXION GLOVE & ELASTIC FINGER FIT/A,3935,CDM,430,RC,L3912,HCPCS,Outpatient,,,283.75,170.25,,241.19,85,,192.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.23,32.15,,72.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.09,80.03,,181.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.38,90,,204.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.23,32.15,,72.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.23,32.15,,72.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.7,88,,199.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,93.95,33.11,,75.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.23,255.38,
Therapy for speech or hearing,322005,CDM,440,RC,92507,HCPCS,Outpatient,,,283.75,170.25,,241.19,85,,192.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.23,32.15,,72.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.09,80.03,,181.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,255.38,90,,204.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.23,32.15,,72.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,91.23,32.15,,72.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.7,88,,199.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,93.95,33.11,,75.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.23,255.38,
"DRESSING, VAC GRANUFOAM THIN",43831,CDM,270,RC,,,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.03,33.11,,75.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.31,255.6,
PYRIDOXAL 5-PHOSPHATE (CSF)  (MAYO),1882694,CDM,300,RC,82542,HCPCS,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,255.6,
GASTROSCOPY TUBE REPLACEMENT,9026,CDM,750,RC,,,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.03,33.11,,75.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.31,255.6,
APPLICATION SKIN SUB GRAFT/FACE/SCALP,15276,CDM,761,RC,15276,HCPCS,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.03,33.11,,75.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.31,255.6,
PACK ORTH I MAJOR ECLIPSE GOWN,498411,CDM,270,RC,,,Outpatient,,,284.25,170.55,,241.61,85,,193.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.39,32.15,,73.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.49,80.03,,181.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.83,90,,204.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.39,32.15,,73.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.39,32.15,,73.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.14,88,,200.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.12,33.11,,75.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.39,255.83,
O/T COMPRESSION SLEEVE,3950,CDM,430,RC,S8424,HCPCS,Outpatient,,,284.75,170.85,,242.04,85,,193.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.89,80.03,,182.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.28,90,,205.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.58,88,,200.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.28,33.11,,75.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.55,256.28,
"PROCEDURE, REPLACEMENT G TUBE",9042,CDM,450,RC,43760,HCPCS,Outpatient,,,284.75,170.85,,242.04,85,,193.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.89,80.03,,182.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.28,90,,205.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.58,88,,200.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.28,33.11,,75.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.55,256.28,
CATHETER CLOSED PRO72 SUCTION,49761,CDM,270,RC,,,Outpatient,,,285.5,171.3,,242.68,85,,194.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.79,32.15,,73.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.49,80.03,,182.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.95,90,,205.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.79,32.15,,73.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.79,32.15,,73.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,251.24,88,,200.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.53,33.11,,75.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.79,256.95,
VALVE DRAIN CHEST HEIMLICH,491473,CDM,270,RC,,,Outpatient,,,287,172.2,,243.95,85,,195.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.27,32.15,,73.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.69,80.03,,183.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.3,90,,206.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.27,32.15,,73.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,92.27,32.15,,73.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,252.56,88,,202.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.03,33.11,,76.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.27,258.3,
PORT HIP BILAT 2V EA HIP,22225,CDM,320,RC,73521,HCPCS,Outpatient,,,287.25,172.35,,244.16,85,,195.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.35,32.15,,73.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.89,80.03,,183.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,258.53,90,,206.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.35,32.15,,73.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,92.35,32.15,,73.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,252.78,88,,202.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.11,33.11,,76.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.35,258.53,
"PORPHYRINS, FECES  (MAYO)",1884126,CDM,300,RC,84126,HCPCS,Outpatient,,,287.5,172.5,,244.38,85,,195.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,230.09,80.03,,184.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,39.89,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,258.75,90,,207,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.89,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,32.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,253,88,,202.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.99,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.03,258.75,
APPLY LONG LEG SPLINT (THIGH TO ANKLE OR,1429505,CDM,450,RC,29505,HCPCS,Outpatient,,,287.62,172.57,,244.48,85,,195.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.47,32.15,,73.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.18,80.03,,184.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,258.86,90,,207.09,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.47,32.15,,73.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,92.47,32.15,,73.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.11,88,,202.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.23,33.11,,76.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.47,258.86,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",22331,CDM,401,RC,77066,HCPCS,Outpatient,,,288,172.8,,244.8,85,,195.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.49,80.03,,184.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,101.75,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,259.2,90,,207.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.75,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.44,88,,202.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.36,33.11,,76.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.59,259.2,
CHOLANGIOGRAM OPERATIVE,22091,CDM,320,RC,74300,HCPCS,Outpatient,,,288.2,172.92,,244.97,85,,195.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.66,32.15,,74.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.65,80.03,,184.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.38,90,,207.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.66,32.15,,74.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,92.66,32.15,,74.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.62,88,,202.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.42,33.11,,76.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.66,259.38,
CYSTOGRAM VOIDING,22160,CDM,320,RC,74455,HCPCS,Outpatient,,,288.2,172.92,,244.97,85,,195.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.66,32.15,,74.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.65,80.03,,184.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,259.38,90,,207.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.66,32.15,,74.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,92.66,32.15,,74.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.62,88,,202.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.42,33.11,,76.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.66,259.38,
INT AUDITORY MEATIUS,22005,CDM,320,RC,70134,HCPCS,Outpatient,,,288.75,173.25,,245.44,85,,196.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.83,32.15,,74.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.09,80.03,,184.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.35,102,,,fee schedule,Pays at 102% of CMS APC rate,259.88,90,,207.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.83,32.15,,74.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.35,100,,,fee schedule,Pays at 100% of CMS APC rate,92.83,32.15,,74.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.1,88,,203.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.61,33.11,,76.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.83,259.88,
MOLDED DISTAL CUSHION,499928,CDM,270,RC,L5668,HCPCS,Outpatient,,,289,173.4,,245.65,85,,196.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.29,80.03,,185.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.1,90,,208.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.32,88,,203.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.69,33.11,,76.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.91,260.1,
PORT MANDIBLE 4V,22231,CDM,320,RC,70110,HCPCS,Outpatient,,,289,173.4,,245.65,85,,196.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.29,80.03,,185.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,260.1,90,,208.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.32,88,,203.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.69,33.11,,76.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.91,260.1,
PORT MASTOIDS 3V EA SIDE,22232,CDM,320,RC,70130,HCPCS,Outpatient,,,289,173.4,,245.65,85,,196.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.29,80.03,,185.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,260.1,90,,208.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.32,88,,203.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.69,33.11,,76.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.91,260.1,
PORT ORBITS 4V,22235,CDM,320,RC,70200,HCPCS,Outpatient,,,289,173.4,,245.65,85,,196.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.29,80.03,,185.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,260.1,90,,208.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.32,88,,203.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.69,33.11,,76.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.91,260.1,
"Radiologic examination of the middle spine, 2 views",22251,CDM,320,RC,72070,HCPCS,Outpatient,,,289,173.4,,245.65,85,,196.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.29,80.03,,185.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,260.1,90,,208.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.32,88,,203.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.69,33.11,,76.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.91,260.1,
PORT THORACOLUMBAR AP/LAT 2V,22252,CDM,320,RC,72080,HCPCS,Outpatient,,,289,173.4,,245.65,85,,196.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.29,80.03,,185.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,260.1,90,,208.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.32,88,,203.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.69,33.11,,76.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.91,260.1,
EMERGENCY SURGERY AFTER HOURS,9015,CDM,360,RC,,,Outpatient,,,289,173.4,,245.65,85,,196.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.29,80.03,,185.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.1,90,,208.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,92.91,32.15,,74.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.32,88,,203.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.69,33.11,,76.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.91,260.1,
DEBRIDEMENT OPEN WOUND EA ADD 20 SQ CM,97598,CDM,761,RC,97598,HCPCS,Outpatient,,,289.05,173.43,,245.69,85,,196.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.93,32.15,,74.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.33,80.03,,185.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.15,90,,208.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.93,32.15,,74.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,92.93,32.15,,74.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.36,88,,203.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.7,33.11,,76.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.93,260.15,
NM WALL MOTION,23058,CDM,341,RC,78451,HCPCS,Outpatient,,,289.75,173.85,,246.29,85,,197.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.15,32.15,,74.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.89,80.03,,185.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,260.78,90,,208.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.15,32.15,,74.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,93.15,32.15,,74.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.98,88,,203.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.94,33.11,,76.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.15,260.78,
LOCAL FOR OR,13045,CDM,370,RC,,,Outpatient,,,289.75,173.85,,246.29,85,,197.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.15,32.15,,74.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.89,80.03,,185.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.78,90,,208.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.15,32.15,,74.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.15,32.15,,74.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.98,88,,203.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.94,33.11,,76.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.15,260.78,
CROUPETTE/DAY,30040,CDM,270,RC,,,Outpatient,,,290,174,,246.5,85,,197.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.09,80.03,,185.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261,90,,208.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.2,88,,204.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.02,33.11,,76.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.24,261,
IVP,22095,CDM,320,RC,74400,HCPCS,Outpatient,,,290,174,,246.5,85,,197.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.09,80.03,,185.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,261,90,,208.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.2,88,,204.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.02,33.11,,76.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.24,261,
IVP INFUSION DRIP,22097,CDM,320,RC,74410,HCPCS,Outpatient,,,290,174,,246.5,85,,197.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.09,80.03,,185.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,261,90,,208.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,93.24,32.15,,74.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.2,88,,204.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.02,33.11,,76.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.24,261,
ERCP,22093,CDM,320,RC,74328,HCPCS,Outpatient,,,290.5,174.3,,246.93,85,,197.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.4,32.15,,74.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.49,80.03,,185.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.45,90,,209.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.4,32.15,,74.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.4,32.15,,74.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.64,88,,204.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.18,33.11,,76.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.4,261.45,
LAVAGE (GASTRIC) KIT-TUM-E-VAC,491305,CDM,270,RC,,,Outpatient,,,291,174.6,,247.35,85,,197.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.56,32.15,,74.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.89,80.03,,186.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.9,90,,209.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.56,32.15,,74.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.56,32.15,,74.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.08,88,,204.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.35,33.11,,77.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.56,261.9,
FLUORO LOC NEEDLE BX,22113,CDM,320,RC,76003,HCPCS,Outpatient,,,291,174.6,,247.35,85,,197.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.56,32.15,,74.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.89,80.03,,186.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.9,90,,209.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.56,32.15,,74.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.56,32.15,,74.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.08,88,,204.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.35,33.11,,77.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.56,261.9,
STAPLER TA 45-35 DLU,4999023,CDM,270,RC,,,Outpatient,,,291.75,175.05,,247.99,85,,198.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.8,32.15,,75.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.49,80.03,,186.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.58,90,,210.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.8,32.15,,75.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.8,32.15,,75.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.74,88,,205.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.6,33.11,,77.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.8,262.58,
CARDIAC REHAB I W/OUT EKG MONITORING,3995,CDM,943,RC,93797,HCPCS,Outpatient,,,292,175.2,,248.2,85,,198.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.88,32.15,,75.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.69,80.03,,186.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,115.11,102,,,fee schedule,Pays at 102% of CMS APC rate,262.8,90,,210.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.88,32.15,,75.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.11,100,,,fee schedule,Pays at 100% of CMS APC rate,93.88,32.15,,75.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.96,88,,205.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.68,33.11,,77.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.88,262.8,
CARDENE 20MG/200ML INFUSION,296112,CDM,258,RC,J1250,HCPCS,Outpatient,,,292.75,175.65,,248.84,85,,199.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,234.29,80.03,,187.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,263.48,90,,210.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,9.82,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,257.62,88,,206.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,9.82,263.48,
PRECEDEX (dexmedetomidine) 4 MCG/ML,293834,CDM,250,RC,,,Outpatient,,,293,175.8,,249.05,85,,199.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,94.2,32.15,,75.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.49,80.03,,187.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,263.7,90,,210.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,94.2,32.15,,75.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,94.2,32.15,,75.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,257.84,88,,206.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.01,33.11,,77.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,94.2,263.7,
Test to measure how well gases diffuse across lung surfaces,3080,CDM,460,RC,94729,HCPCS,Outpatient,,,294,176.4,,249.9,85,,199.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.29,80.03,,188.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,264.6,90,,211.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.72,88,,206.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.34,33.11,,77.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,94.52,264.6,
Outpatient visit of established patient not requiring a physician,11003,CDM,510,RC,99211,HCPCS,Outpatient,,,294,176.4,,249.9,85,,199.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.29,80.03,,188.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,264.6,90,,211.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.72,88,,206.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.34,33.11,,77.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,94.52,264.6,
VISIT - ESTABLISHED PATIENT - LEVEL 1,99211,CDM,510,RC,G0463,HCPCS,Outpatient,,,294,176.4,,249.9,85,,199.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.29,80.03,,188.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,115.86,102,,,fee schedule,Pays at 102% of CMS APC rate,264.6,90,,211.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.86,100,,,fee schedule,Pays at 100% of CMS APC rate,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.72,88,,206.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.34,33.11,,77.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,94.52,264.6,
"CHLAMYDIA PANEL, SERUM (MAYO)",1886632,CDM,300,RC,86631,HCPCS,Outpatient,,,294.5,176.7,,250.33,85,,200.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,235.69,80.03,,188.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.05,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,265.05,90,,212.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.05,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,259.16,88,,207.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.87,265.05,
"Established patient office or other outpatient visit, typically 15 minutes",99213,CDM,510,RC,99213,HCPCS,Outpatient,,,295,177,,250.75,85,,200.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,94.84,32.15,,75.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.09,80.03,,188.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.5,90,,212.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,94.84,32.15,,75.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,94.84,32.15,,75.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,259.6,88,,207.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.67,33.11,,78.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,94.84,265.5,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,13034,CDM,370,RC,62322,HCPCS,Outpatient,,,295.63,177.38,,251.29,85,,201.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.05,32.15,,76.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.59,80.03,,189.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,266.07,90,,212.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.05,32.15,,76.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,95.05,32.15,,76.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.15,88,,208.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.88,33.11,,78.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.05,266.07,
CULTURE AFB TISSUE (MAYO),1887118,CDM,300,RC,87116,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
MANDIBLE,22003,CDM,320,RC,70110,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
FACIAL BONES 3V,22007,CDM,320,RC,70150,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
ORBITS 4V,22010,CDM,320,RC,70200,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
SKULL LIMITED <4V,22014,CDM,320,RC,70250,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
SKULL COMPLETE 4V,22015,CDM,320,RC,70260,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
RIBS BILAT 4V,22028,CDM,320,RC,71111,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
"Radiologic examination of the middle spine, 2 views",22036,CDM,320,RC,72070,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
LUMBAR FLEX & EXT,22040,CDM,320,RC,72114,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
SACROILIAC JOINTS <3V,22045,CDM,320,RC,72200,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
SCAPULA,22050,CDM,320,RC,73010,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
HIP BILAT 2V EA HIP,22065,CDM,320,RC,73521,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
SMALL BOWEL SERIES,22086,CDM,320,RC,74250,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
MODIFIED BARIUM SWALLOW W VIDEO,22129,CDM,320,RC,74230,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
SKELETAL SURVEY FOR METASTASES,22145,CDM,320,RC,77075,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
X-ray of the hand with 2 views,22197,CDM,320,RC,73120,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
X-ray of the hand with 2 views,22198,CDM,320,RC,73120,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
PORT ABDOMEN FLAT/UPRIGHT,22203,CDM,320,RC,74021,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Radiologic examination of the pelvis,22237,CDM,320,RC,72170,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
X-ray of the lower spine 2-3 views,22250,CDM,320,RC,72100,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Radiologic examination of the knee with 4 or more views,22260,CDM,320,RC,73564,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
RIBS BILAT 3V,22271,CDM,320,RC,71110,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Radiologic examination of the knee with 4 or more views,22288,CDM,320,RC,73564,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
SACROILIAC JOINTS 3V,22313,CDM,320,RC,72202,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
"Radiologic examination of the neck/spine, 4-5 views",22318,CDM,320,RC,72050,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
THORACIC 4V,22347,CDM,320,RC,72074,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Radiologic examination of the knee with 4 or more views,22502,CDM,320,RC,73564,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Radiologic examination of the knee with 4 or more views,22503,CDM,320,RC,73564,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Radiologic examination of the knee with 4 or more views,22568,CDM,320,RC,73564,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
US KNEE POPLITEAL AREA NON-VASCULAR,24024,CDM,402,RC,76881,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Ultrasound of the pelvis through vagina,24041,CDM,402,RC,76830,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Ultrasound of back wall of the abdomen with limited areas viewed,24094,CDM,402,RC,76775,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Ultrasound of abdomen with all areas scanned,24100,CDM,402,RC,76700,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",24109,CDM,402,RC,76882,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
US BREAST UNILATERAL COMPLETE LT,24111,CDM,402,RC,76641,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
US BREAST UNILATERAL COMPLETE RT,24112,CDM,402,RC,76641,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Ultrasound of head and neck,24114,CDM,402,RC,76536,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
US GROIN,24131,CDM,402,RC,76881,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24132,CDM,402,RC,76705,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
Ultrasound of fetus with limited views,624017,CDM,402,RC,76815,HCPCS,Outpatient,,,296,177.6,,251.6,85,,201.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.89,80.03,,189.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,266.4,90,,213.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,95.16,32.15,,76.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.48,88,,208.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.01,33.11,,78.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.16,266.4,
JUG-OMNI W/SPECIMEN TRAP,498335,CDM,270,RC,,,Outpatient,,,296.25,177.75,,251.81,85,,201.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.24,32.15,,76.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.09,80.03,,189.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266.63,90,,213.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.24,32.15,,76.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,95.24,32.15,,76.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.7,88,,208.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.09,33.11,,78.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.24,266.63,
TRAY THORACENTESIS/PARACENTESIS,49265,CDM,270,RC,,,Outpatient,,,296.88,178.13,,252.35,85,,201.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.45,32.15,,76.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.59,80.03,,190.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.19,90,,213.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.45,32.15,,76.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,95.45,32.15,,76.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.25,88,,209,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.3,33.11,,78.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.45,267.19,
"MONOCLONAL GAMMOPATHY, DIAGNOSTIC (MAYO)",1884202,CDM,300,RC,83520,HCPCS,Outpatient,,,297.17,178.3,,252.59,85,,202.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,237.83,80.03,,190.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,267.45,90,,213.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,261.51,88,,209.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,267.45,
.HUMAN ALBUMIN 50G,2096395,CDM,636,RC,P9046,HCPCS,Outpatient,,,297.25,178.35,,252.66,85,,202.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,237.89,80.03,,190.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.65,102,,,fee schedule,Pays at 102% of CMS APC rate,267.53,90,,214.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.65,100,,,fee schedule,Pays at 100% of CMS APC rate,21.23,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,261.58,88,,209.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.23,267.53,
NM THALLIUM KIT,2932297,CDM,636,RC,A9505,HCPCS,Outpatient,,,297.42,178.45,,252.81,85,,202.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.62,32.15,,76.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,238.03,80.03,,190.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.68,90,,214.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.62,32.15,,76.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,95.62,32.15,,76.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.73,88,,209.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.48,33.11,,78.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.62,267.68,
US ASPIRATION OF BREAST,24032,CDM,761,RC,19000,HCPCS,Outpatient,,,297.5,178.5,,252.88,85,,202.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.65,32.15,,76.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,238.09,80.03,,190.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,267.75,90,,214.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.65,32.15,,76.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,95.65,32.15,,76.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.8,88,,209.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.5,33.11,,78.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.65,267.75,
Use of EKG to monitor cardiac rehabilitation,1398,CDM,943,RC,93798,HCPCS,Outpatient,,,297.69,178.61,,253.04,85,,202.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.71,32.15,,76.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,238.24,80.03,,190.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,115.11,102,,,fee schedule,Pays at 102% of CMS APC rate,267.92,90,,214.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.71,32.15,,76.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,115.11,100,,,fee schedule,Pays at 100% of CMS APC rate,95.71,32.15,,76.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.97,88,,209.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.57,33.11,,78.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.71,267.92,
PTH AB  (MAYO),1883970,CDM,300,RC,83519,HCPCS,Outpatient,,,298,178.8,,253.3,85,,202.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,238.49,80.03,,190.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,268.2,90,,214.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,262.24,88,,209.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,268.2,
"STACLOT LA, P (MAYO)",1885311,CDM,300,RC,85598,HCPCS,Outpatient,,,298,178.8,,253.3,85,,202.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,238.49,80.03,,190.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,268.2,90,,214.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,262.24,88,,209.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.24,268.2,
COLOSTOMY/ILEOSTOMY POSTOPERATIVE 1 3/4,493231,CDM,270,RC,,,Outpatient,,,298.25,178.95,,253.51,85,,202.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.89,32.15,,76.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,238.69,80.03,,190.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.43,90,,214.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.89,32.15,,76.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,95.89,32.15,,76.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.46,88,,209.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.75,33.11,,79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.89,268.43,
US GUIDANCE PROCEDURES,24093,CDM,320,RC,76942,HCPCS,Outpatient,,,298.5,179.1,,253.73,85,,202.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.97,32.15,,76.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,238.89,80.03,,191.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.65,90,,214.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.97,32.15,,76.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,95.97,32.15,,76.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.68,88,,210.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.83,33.11,,79.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.97,268.65,
Radiologic examination of the shoulder,22052,CDM,320,RC,73030,HCPCS,Outpatient,,,298.75,179.25,,253.94,85,,203.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.09,80.03,,191.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,268.88,90,,215.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.9,88,,210.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.92,33.11,,79.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.05,268.88,
PORT FACIAL BONES 3V,22217,CDM,320,RC,70150,HCPCS,Outpatient,,,298.75,179.25,,253.94,85,,203.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.09,80.03,,191.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,268.88,90,,215.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.9,88,,210.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.92,33.11,,79.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.05,268.88,
Radiologic examination of the shoulder,22452,CDM,320,RC,73030,HCPCS,Outpatient,,,298.75,179.25,,253.94,85,,203.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.09,80.03,,191.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,268.88,90,,215.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.9,88,,210.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.92,33.11,,79.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.05,268.88,
FETAL MONITORING EXTERNAL/INTERNAL,6030,CDM,721,RC,59050,HCPCS,Outpatient,,,298.75,179.25,,253.94,85,,203.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.09,80.03,,191.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.88,90,,215.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.9,88,,210.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.92,33.11,,79.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.05,268.88,
FETAL MONITORING (1 HR),6500,CDM,721,RC,,,Outpatient,,,298.75,179.25,,253.94,85,,203.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.09,80.03,,191.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.88,90,,215.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,96.05,32.15,,76.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.9,88,,210.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.92,33.11,,79.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.05,268.88,
S/T FEEDING/SWALLOWING TX 15-Min,3220025,CDM,440,RC,92526,HCPCS,Outpatient,,,299,179.4,,254.15,85,,203.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.29,80.03,,191.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,82.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,269.1,90,,215.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,263.12,88,,210.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99,33.11,,79.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.13,269.1,
S/T 30-Min FEEDING/SWALLOWING TX,3220026,CDM,440,RC,92526,HCPCS,Outpatient,,,299,179.4,,254.15,85,,203.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.29,80.03,,191.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,82.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,269.1,90,,215.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,263.12,88,,210.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99,33.11,,79.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.13,269.1,
S/T FEEDING/SWALLOWING Tx 45-Min,3220027,CDM,440,RC,92526,HCPCS,Outpatient,,,299,179.4,,254.15,85,,203.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.29,80.03,,191.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,82.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,269.1,90,,215.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,263.12,88,,210.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99,33.11,,79.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.13,269.1,
S/T FEEDING/SWALLOWING TREATMENT IV,3220028,CDM,440,RC,92526,HCPCS,Outpatient,,,299,179.4,,254.15,85,,203.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.29,80.03,,191.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,82.73,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,269.1,90,,215.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.73,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,263.12,88,,210.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99,33.11,,79.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.13,269.1,
"DRVVT, MIX  (MAYO)",1885215,CDM,300,RC,85613,HCPCS,Outpatient,,,300,180,,255,85,,204,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,240.09,80.03,,192.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,9.77,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,270,90,,216,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,9.77,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,12.03,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,264,88,,211.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.39,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12.03,270,
CATHETER 3F ARTERIAL EMBOLECTOMY FOGARTY,49592,CDM,272,RC,C1757,HCPCS,Outpatient,,,301,180.6,,255.85,85,,204.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.89,80.03,,192.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270.9,90,,216.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301,,,,Other,Not Separately reimbursable,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.88,88,,211.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.66,33.11,,79.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.77,270.9,
INTERPHALAN DISLOC CLOSED/C AN,1426472,CDM,450,RC,,,Outpatient,,,302,181.2,,256.7,85,,205.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.09,32.15,,77.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,241.69,80.03,,193.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,271.8,90,,217.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.09,32.15,,77.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,302,,,,Other,Not Separately reimbursable,97.09,32.15,,77.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.76,88,,212.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.99,33.11,,79.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.09,271.8,
ADDITIONAL 1/2HR CRITICAL CARE,1499292,CDM,450,RC,99292,HCPCS,Outpatient,,,302,181.2,,256.7,85,,205.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.09,32.15,,77.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,241.69,80.03,,193.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,271.8,90,,217.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.09,32.15,,77.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,302,,,,Other,Not Separately reimbursable,97.09,32.15,,77.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.76,88,,212.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.99,33.11,,79.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.09,271.8,
CARBAPENEMASE-CARBA NP TEST  (MAYO),1882682,CDM,300,RC,87185,HCPCS,Outpatient,,,302.25,181.35,,256.91,85,,205.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,241.89,80.03,,193.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4.84,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,272.03,90,,217.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4.84,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,5.98,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,265.98,88,,212.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.98,272.03,
LARYNGOSCOPY DIAGNOSTIC,1431505,CDM,450,RC,31505,HCPCS,Outpatient,,,302.25,181.35,,256.91,85,,205.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,241.89,80.03,,193.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,171.36,102,,,fee schedule,Pays at 102% of CMS APC rate,272.03,90,,217.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.36,100,,,fee schedule,Pays at 100% of CMS APC rate,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.98,88,,212.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.07,33.11,,80.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.17,272.03,
LARYNGOSCOPY W/FB REM,1431511,CDM,450,RC,31511,HCPCS,Outpatient,,,302.25,181.35,,256.91,85,,205.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,241.89,80.03,,193.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,171.36,102,,,fee schedule,Pays at 102% of CMS APC rate,272.03,90,,217.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.36,100,,,fee schedule,Pays at 100% of CMS APC rate,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.98,88,,212.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.07,33.11,,80.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.17,272.03,
"Flexible, fiberoptic diagnostic laryngoscopy",1431575,CDM,450,RC,31575,HCPCS,Outpatient,,,302.25,181.35,,256.91,85,,205.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,241.89,80.03,,193.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,171.36,102,,,fee schedule,Pays at 102% of CMS APC rate,272.03,90,,217.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.36,100,,,fee schedule,Pays at 100% of CMS APC rate,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.98,88,,212.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.07,33.11,,80.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.17,272.03,
NASOPHARYNGOSCOPY W/ENDOSCOPE (SEPARATE,1492511,CDM,450,RC,92511,HCPCS,Outpatient,,,302.25,181.35,,256.91,85,,205.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,241.89,80.03,,193.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,171.36,102,,,fee schedule,Pays at 102% of CMS APC rate,272.03,90,,217.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.36,100,,,fee schedule,Pays at 100% of CMS APC rate,97.17,32.15,,77.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.98,88,,212.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.07,33.11,,80.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.17,272.03,
pneumococcal Pneumococcal vaccine,296049,CDM,636,RC,90732,HCPCS,Outpatient,,,302.88,181.73,,257.45,85,,205.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,242.39,80.03,,193.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.59,90,,218.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,133.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,266.53,88,,213.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.47,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,133.47,272.59,
"SOMATOMEDIN-C, INSULIN-LIKE GROWTH PANEL",1884305,CDM,300,RC,84305,HCPCS,Outpatient,,,303.25,181.95,,257.76,85,,206.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,242.69,80.03,,194.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,21.68,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,272.93,90,,218.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.68,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,26.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,266.86,88,,213.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.73,272.93,
CRYOPRECIPITATE,2086202,CDM,390,RC,,,Outpatient,,,304.75,182.85,,259.04,85,,207.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.98,32.15,,78.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,243.89,80.03,,195.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274.28,90,,219.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.98,32.15,,78.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,97.98,32.15,,78.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.18,88,,214.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.9,33.11,,80.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.98,274.28,
O/T LMB SPRING COIL EXT. FINGER SPLINT,3958,CDM,274,RC,L3928,HCPCS,Outpatient,,,305.25,183.15,,259.46,85,,207.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,244.29,80.03,,195.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274.73,90,,219.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.62,88,,214.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.07,33.11,,80.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.14,274.73,
US LIMITED ECHO,24200,CDM,402,RC,93308,HCPCS,Outpatient,,,305.25,183.15,,259.46,85,,207.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,244.29,80.03,,195.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,274.73,90,,219.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.62,88,,214.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.07,33.11,,80.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.14,274.73,
Therapy for speech or hearing,3220015,CDM,440,RC,92507,HCPCS,Outpatient,,,305.25,183.15,,259.46,85,,207.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,244.29,80.03,,195.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,274.73,90,,219.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,98.14,32.15,,78.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.62,88,,214.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.07,33.11,,80.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.14,274.73,
B CELLS TOTAL COUNT  (MAYO),1882696,CDM,300,RC,86355,HCPCS,Outpatient,,,305.5,183.3,,259.68,85,,207.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,244.49,80.03,,195.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,38.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,274.95,90,,219.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,38.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,29.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,268.84,88,,215.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,29.62,274.95,
CERVIDIL (dinoprostone) 10MG INSERT,296087,CDM,250,RC,,,Outpatient,,,306,183.6,,260.1,85,,208.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.38,32.15,,78.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,244.89,80.03,,195.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.4,90,,220.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.38,32.15,,78.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,98.38,32.15,,78.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,269.28,88,,215.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.32,33.11,,81.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.38,275.4,
SURGICEL 1/2 X 2,493352,CDM,270,RC,,,Outpatient,,,306.68,184.01,,260.68,85,,208.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.6,32.15,,78.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.44,80.03,,196.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276.01,90,,220.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.6,32.15,,78.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,98.6,32.15,,78.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,269.88,88,,215.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.54,33.11,,81.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.6,276.01,
ANA ID PANEL  (MAYO),1887071,CDM,300,RC,87076,HCPCS,Outpatient,,,307.4,184.44,,261.29,85,,209.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,246.01,80.03,,196.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.24,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,276.66,90,,221.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.24,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,270.51,88,,216.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.16,276.66,
Incision and drainage of abscess; simple or single and complex or multiple,3014,CDM,450,RC,10060,HCPCS,Outpatient,,,307.5,184.5,,261.38,85,,209.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.86,32.15,,79.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,246.09,80.03,,196.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,276.75,90,,221.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.86,32.15,,79.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,98.86,32.15,,79.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,270.6,88,,216.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.81,33.11,,81.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.86,276.75,
KPC - PCR  (MAYO).,1887158,CDM,300,RC,87798,HCPCS,Outpatient,,,308.25,184.95,,262.01,85,,209.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,246.69,80.03,,197.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,277.43,90,,221.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,271.26,88,,217.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,277.43,
NDM - PCR  (MAYO).,1887159,CDM,300,RC,87798,HCPCS,Outpatient,,,308.25,184.95,,262.01,85,,209.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,246.69,80.03,,197.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,277.43,90,,221.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,271.26,88,,217.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,277.43,
PERTRACH ADULT 5.6MM EMEG TRACH KIT,49218,CDM,270,RC,,,Outpatient,,,308.5,185.1,,262.23,85,,209.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.18,32.15,,79.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,246.89,80.03,,197.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.65,90,,222.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.18,32.15,,79.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,99.18,32.15,,79.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.48,88,,217.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.14,33.11,,81.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.18,277.65,
CHOLANGIOGRAM T-TUBE,22092,CDM,320,RC,47531,HCPCS,Outpatient,,,308.75,185.25,,262.44,85,,209.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.09,80.03,,197.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3395.67,102,,,fee schedule,Pays at 102% of CMS APC rate,277.88,90,,222.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3395.67,100,,,fee schedule,Pays at 100% of CMS APC rate,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.7,88,,217.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.23,33.11,,81.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.26,277.88,
OR CHOLANGIOGRAM OPERATIVE,22183,CDM,320,RC,74300,HCPCS,Outpatient,,,308.75,185.25,,262.44,85,,209.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.09,80.03,,197.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.88,90,,222.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.7,88,,217.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.23,33.11,,81.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.26,277.88,
PORT RIBS BILAT 4V,22239,CDM,320,RC,71111,HCPCS,Outpatient,,,308.75,185.25,,262.44,85,,209.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.09,80.03,,197.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,277.88,90,,222.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.7,88,,217.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.23,33.11,,81.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.26,277.88,
Mammography of both breasts-2 or more views,22332,CDM,403,RC,77067,HCPCS,Outpatient,,,308.75,185.25,,262.44,85,,209.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.09,80.03,,197.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,84.39,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,277.88,90,,222.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.39,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,99.26,32.15,,79.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.7,88,,217.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.23,33.11,,81.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.26,277.88,
S/T EVAL BEHAV-QUANT (VOICE/REASONAN),3292524,CDM,440,RC,92524,HCPCS,Outpatient,,,309.5,185.7,,263.08,85,,210.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.5,32.15,,79.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.69,80.03,,198.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,107.79,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,278.55,90,,222.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.5,32.15,,79.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.79,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,99.5,32.15,,79.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.36,88,,217.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.48,33.11,,81.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.5,278.55,
HEPATITIS B VIRAL DNA (HBV-DNA)   (MAYO),1880065,CDM,300,RC,87517,HCPCS,Outpatient,,,309.75,185.85,,263.29,85,,210.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,247.89,80.03,,198.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,43.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,278.78,90,,223.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,43.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,53.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,272.58,88,,218.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,53.87,278.78,
RENAL DISEASE PANEL  (MAYO),1886303,CDM,300,RC,,,Outpatient,,,310.25,186.15,,263.71,85,,210.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.75,32.15,,79.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,248.29,80.03,,198.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.23,90,,223.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.75,32.15,,79.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,99.75,32.15,,79.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,273.02,88,,218.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.72,33.11,,82.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.75,279.23,
"Radiologic examination of the neck/spine, 4-5 views",22444,CDM,320,RC,72050,HCPCS,Outpatient,,,310.5,186.3,,263.93,85,,211.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.83,32.15,,79.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,248.49,80.03,,198.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,279.45,90,,223.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.83,32.15,,79.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,99.83,32.15,,79.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,273.24,88,,218.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.81,33.11,,82.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.83,279.45,
"CEA, PLEURAL FLUID  (MAYO)",1882378,CDM,300,RC,82378,HCPCS,Outpatient,,,311,186.6,,264.35,85,,211.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,248.89,80.03,,199.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,279.9,90,,223.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,273.68,88,,218.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.86,279.9,
DEGLYCEROLIZED RED BLOOD CELLS,2086670,CDM,391,RC,86999,HCPCS,Outpatient,,,311,186.6,,264.35,85,,211.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.99,32.15,,79.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,248.89,80.03,,199.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,279.9,90,,223.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.99,32.15,,79.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,99.99,32.15,,79.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,273.68,88,,218.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.97,33.11,,82.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.99,279.9,
HLA  A29 BLOOD  (MAYO),1886815,CDM,300,RC,81374,HCPCS,Outpatient,,,311.5,186.9,,264.78,85,,211.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,249.29,80.03,,199.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,75.81,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,280.35,90,,224.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,75.81,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,98.4,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,274.12,88,,219.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,101.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,98.4,280.35,
ANEST SUP EA ADD 15MIN-OR,13011,CDM,370,RC,,,Outpatient,,,311.88,187.13,,265.1,85,,212.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,100.27,32.15,,80.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.6,80.03,,199.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.69,90,,224.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,100.27,32.15,,80.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.27,32.15,,80.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.45,88,,219.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,103.26,33.11,,82.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,100.27,280.69,
EZ-IO 25MM NEEDLE SET VASCULAR ACCESS,49920,CDM,270,RC,,,Outpatient,,,313.5,188.1,,266.48,85,,213.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,100.79,32.15,,80.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.89,80.03,,200.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.15,90,,225.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,100.79,32.15,,80.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.79,32.15,,80.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,275.88,88,,220.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,103.8,33.11,,83.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,100.79,282.15,
EZ-IO 45MM NEEDLE SET VASCULAR ACCESS,49921,CDM,270,RC,,,Outpatient,,,313.5,188.1,,266.48,85,,213.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,100.79,32.15,,80.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.89,80.03,,200.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.15,90,,225.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,100.79,32.15,,80.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.79,32.15,,80.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,275.88,88,,220.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,103.8,33.11,,83.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,100.79,282.15,
"AMINO ACID, URINE, QT  (MAYO)",1882131,CDM,300,RC,82139,HCPCS,Outpatient,,,313.5,188.1,,266.48,85,,213.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,250.89,80.03,,200.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,282.15,90,,225.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,21.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,275.88,88,,220.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,21.21,282.15,
MIOCHOL-E INTRAOCULAR SOLN 20MG/2ML,303966,CDM,250,RC,,,Outpatient,,,314.04,188.42,,266.93,85,,213.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,100.96,32.15,,80.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,251.33,80.03,,201.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.64,90,,226.11,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,100.96,32.15,,80.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.96,32.15,,80.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.36,88,,221.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,103.98,33.11,,83.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,100.96,282.64,
BONE LENGTH STUDY,22118,CDM,320,RC,77073,HCPCS,Outpatient,,,314.75,188.85,,267.54,85,,214.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.19,32.15,,80.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,251.89,80.03,,201.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,283.28,90,,226.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.19,32.15,,80.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,101.19,32.15,,80.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.98,88,,221.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.21,33.11,,83.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.19,283.28,
COLPOSCOPY,1457452,CDM,450,RC,57452,HCPCS,Outpatient,,,314.75,188.85,,267.54,85,,214.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.19,32.15,,80.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,251.89,80.03,,201.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,170.77,102,,,fee schedule,Pays at 102% of CMS APC rate,283.28,90,,226.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.19,32.15,,80.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.77,100,,,fee schedule,Pays at 100% of CMS APC rate,101.19,32.15,,80.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.98,88,,221.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.21,33.11,,83.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.19,283.28,
NM CHOLETEC,2932282,CDM,343,RC,A9537,HCPCS,Outpatient,,,315.3,189.18,,268.01,85,,214.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.37,32.15,,81.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,252.33,80.03,,201.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.77,90,,227.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.37,32.15,,81.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,101.37,32.15,,81.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,277.46,88,,221.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.4,33.11,,83.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.37,283.77,
"FUNGAL ID, D2F1  (MAYO)",1887156,CDM,300,RC,87153,HCPCS,Outpatient,,,316.4,189.84,,268.94,85,,215.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.72,32.15,,81.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.21,80.03,,202.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,117.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,284.76,90,,227.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.72,32.15,,81.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,117.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,101.72,32.15,,81.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.43,88,,222.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.76,33.11,,83.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.72,284.76,
SLEEVE EXPAND RADIALLY 12MM VERSASTEP,4980098,CDM,270,RC,,,Outpatient,,,316.5,189.9,,269.03,85,,215.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.75,32.15,,81.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.29,80.03,,202.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,284.85,90,,227.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.75,32.15,,81.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,101.75,32.15,,81.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.52,88,,222.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.79,33.11,,83.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.75,284.85,
"SIM LAC RPR >30.0 CM BODY,SCALP",1412007,CDM,450,RC,12007,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
SIM LAC 5.1-7.5 CM,1412014,CDM,450,RC,12014,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
SIM LAC 12.6-20.0 CM,1412016,CDM,450,RC,12016,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
SIM LAC >30.0 CM,1412018,CDM,450,RC,12018,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
"INT LAC <2.5 CM FACE,EARS,EYES",1412051,CDM,450,RC,12051,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
"INT LAC RPR>30CM FACE,EARS,EYES",1412057,CDM,450,RC,12057,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
INITIAL TX BURN 1ST DEGREE LOCAL TX ONLY,1416000,CDM,450,RC,16000,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
DRESS OR DEBRIDE BURN SMALL 1-2 DEGREE,1416020,CDM,450,RC,16020,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
DRESS OR DEBRIDE BURN MED 1-2 DEGREE,1416025,CDM,450,RC,16025,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
I & D FINGER ABSCESS SIMPLE,1426010,CDM,450,RC,26010,HCPCS,Outpatient,,,316.75,190.05,,269.24,85,,215.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.5,80.03,,202.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,285.08,90,,228.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,101.84,32.15,,81.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.74,88,,222.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.88,33.11,,83.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.84,285.08,
GUIDEWIRE .038 STIFF BODIED PTFE 150CM,4999042,CDM,272,RC,,,Outpatient,,,317,190.2,,269.45,85,,215.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,101.92,32.15,,81.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.7,80.03,,202.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285.3,90,,228.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,101.92,32.15,,81.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,101.92,32.15,,81.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,278.96,88,,223.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,104.96,33.11,,83.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,101.92,285.3,
I & D EX AUDITORY CANAL,1469020,CDM,450,RC,69020,HCPCS,Outpatient,,,318,190.8,,270.3,85,,216.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.24,32.15,,81.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.5,80.03,,203.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,286.2,90,,228.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.24,32.15,,81.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,102.24,32.15,,81.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.84,88,,223.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.29,33.11,,84.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.24,286.2,
VACCUM ASPIRATOR,6020,CDM,270,RC,,,Outpatient,,,318.75,191.25,,270.94,85,,216.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.1,80.03,,204.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.88,90,,229.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.5,88,,224.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.54,33.11,,84.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.48,286.88,
NEPHROSTOGRAM,22151,CDM,320,RC,74425,HCPCS,Outpatient,,,318.75,191.25,,270.94,85,,216.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.1,80.03,,204.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,286.88,90,,229.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.5,88,,224.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.54,33.11,,84.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.48,286.88,
"Radiologic examination, elbow; 2 views",22345,CDM,320,RC,73070,HCPCS,Outpatient,,,318.75,191.25,,270.94,85,,216.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.1,80.03,,204.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,286.88,90,,229.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.5,88,,224.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.54,33.11,,84.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.48,286.88,
Radiologic examination of the foot with 3 or more views,22403,CDM,320,RC,73630,HCPCS,Outpatient,,,318.75,191.25,,270.94,85,,216.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.1,80.03,,204.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,286.88,90,,229.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.5,88,,224.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.54,33.11,,84.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.48,286.88,
NM EF,23059,CDM,341,RC,78451,HCPCS,Outpatient,,,319,191.4,,271.15,85,,216.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.3,80.03,,204.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,287.1,90,,229.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.72,88,,224.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.62,33.11,,84.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.56,287.1,
ISOVUE 370  100ML,265026,CDM,255,RC,,,Outpatient,,,319.25,191.55,,271.36,85,,217.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.64,32.15,,82.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.5,80.03,,204.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,287.33,90,,229.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.64,32.15,,82.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,102.64,32.15,,82.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.94,88,,224.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.7,33.11,,84.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.64,287.33,
PERSANTINE (dipyridamole)5MG/ML:10MLVIAL,293408,CDM,250,RC,J1245,HCPCS,Outpatient,,,319.5,191.7,,271.58,85,,217.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,255.7,80.03,,204.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,287.55,90,,230.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,281.16,88,,224.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.69,287.55,
"CALPROTECTIN, STOOL  (MAYO)",1883993,CDM,300,RC,83993,HCPCS,Outpatient,,,319.5,191.7,,271.58,85,,217.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,255.7,80.03,,204.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.02,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,287.55,90,,230.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.02,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.68,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,281.16,88,,224.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.68,287.55,
I & D REM FOREIGN BODY - SIMPLE,8410120,CDM,360,RC,10120,HCPCS,Outpatient,,,319.75,191.85,,271.79,85,,217.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.8,32.15,,82.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.9,80.03,,204.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,287.78,90,,230.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.8,32.15,,82.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,102.8,32.15,,82.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,281.38,88,,225.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.87,33.11,,84.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.8,287.78,
CHEST INSTRUMENT,49463,CDM,270,RC,,,Outpatient,,,320.25,192.15,,272.21,85,,217.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.96,32.15,,82.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.3,80.03,,205.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.23,90,,230.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.96,32.15,,82.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,102.96,32.15,,82.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,281.82,88,,225.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.03,33.11,,84.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.96,288.23,
SUTURE 0 VLOC 180 ABS 24  GS-21,4999100,CDM,270,RC,,,Outpatient,,,320.5,192.3,,272.43,85,,217.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.5,80.03,,205.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.45,90,,230.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.04,88,,225.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.12,33.11,,84.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.04,288.45,
SUTURE 3.0 VLOC 180 ABS CL 18  P-12,4999102,CDM,270,RC,,,Outpatient,,,320.5,192.3,,272.43,85,,217.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.5,80.03,,205.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.45,90,,230.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.04,88,,225.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.12,33.11,,84.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.04,288.45,
SUTURE 0 VLOC 180 18  GS-11,4999103,CDM,270,RC,,,Outpatient,,,320.5,192.3,,272.43,85,,217.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.5,80.03,,205.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.45,90,,230.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.04,88,,225.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.12,33.11,,84.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.04,288.45,
"Established patient office or other outpatient visit, typically 25 minutes",99214,CDM,510,RC,99214,HCPCS,Outpatient,,,320.5,192.3,,272.43,85,,217.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.5,80.03,,205.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.45,90,,230.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,103.04,32.15,,82.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.04,88,,225.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.12,33.11,,84.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.04,288.45,
CHLAMYDIA PNEUMONIAE DNA-PCR  (MAYO),1887486,CDM,300,RC,87486,HCPCS,Outpatient,,,320.75,192.45,,272.64,85,,218.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,256.7,80.03,,205.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,288.68,90,,230.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,282.26,88,,225.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,288.68,
"S/T EVAL (ARTIC., APRAX., DYSART, PHONO)",3292522,CDM,440,RC,92522,HCPCS,Outpatient,,,320.75,192.45,,272.64,85,,218.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.12,32.15,,82.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.7,80.03,,205.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,109.01,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,288.68,90,,230.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.12,32.15,,82.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.01,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,103.12,32.15,,82.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.26,88,,225.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.2,33.11,,84.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.12,288.68,
CATHETER CHOLANGIOGRAM 7.5FR X 18,4999020,CDM,270,RC,,,Outpatient,,,322,193.2,,273.7,85,,218.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.52,32.15,,82.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,257.7,80.03,,206.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,289.8,90,,231.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.52,32.15,,82.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,103.52,32.15,,82.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,283.36,88,,226.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.61,33.11,,85.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.52,289.8,
PROCARDIA LEVEL  (MAYO),1884999,CDM,300,RC,80375,HCPCS,Outpatient,,,322,193.2,,273.7,85,,218.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,257.7,80.03,,206.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,289.8,90,,231.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,18.25,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,283.36,88,,226.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,18.25,289.8,
HEPATITIS B IMMUNE GLOBULIN 1ML,293590,CDM,636,RC,J1571,HCPCS,Outpatient,,,322,193.2,,273.7,85,,218.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.52,32.15,,82.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,257.7,80.03,,206.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.4,102,,,fee schedule,Pays at 102% of CMS APC rate,289.8,90,,231.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.52,32.15,,82.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.4,100,,,fee schedule,Pays at 100% of CMS APC rate,103.52,32.15,,82.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,283.36,88,,226.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.61,33.11,,85.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.52,289.8,
ADVAIR 230/21 HFA 12GM,292137,CDM,636,RC,J3535,HCPCS,Outpatient,,,322.45,193.47,,274.08,85,,219.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.67,32.15,,82.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.06,80.03,,206.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.21,90,,232.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.67,32.15,,82.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,103.67,32.15,,82.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,283.76,88,,227.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.76,33.11,,85.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.67,290.21,
4 or more views,22024,CDM,320,RC,71048,HCPCS,Outpatient,,,323,193.8,,274.55,85,,219.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.84,32.15,,83.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.5,80.03,,206.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,290.7,90,,232.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.84,32.15,,83.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,103.84,32.15,,83.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.24,88,,227.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.95,33.11,,85.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.84,290.7,
BONE MARROW BX,22168,CDM,761,RC,38221,HCPCS,Outpatient,,,323.22,193.93,,274.74,85,,219.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.92,32.15,,83.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.67,80.03,,206.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,290.9,90,,232.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.92,32.15,,83.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,103.92,32.15,,83.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.43,88,,227.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.02,33.11,,85.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.92,290.9,
THYROGLOBULIN MASS SPECTROMETRY  (MAYO),1886804,CDM,300,RC,84432,HCPCS,Outpatient,,,323.5,194.1,,274.98,85,,219.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,258.9,80.03,,207.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.38,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,291.15,90,,232.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.38,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.2,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,284.68,88,,227.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.81,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.2,291.15,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",22292,CDM,401,RC,77065,HCPCS,Outpatient,,,324,194.4,,275.4,85,,220.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,259.3,80.03,,207.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.83,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,291.6,90,,233.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.83,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,285.12,88,,228.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.28,33.11,,85.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.17,291.6,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",22330,CDM,401,RC,77065,HCPCS,Outpatient,,,324,194.4,,275.4,85,,220.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,259.3,80.03,,207.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.83,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,291.6,90,,233.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.83,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,285.12,88,,228.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.28,33.11,,85.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.17,291.6,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",22334,CDM,401,RC,77065,HCPCS,Outpatient,,,324,194.4,,275.4,85,,220.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,259.3,80.03,,207.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.83,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,291.6,90,,233.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.83,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,104.17,32.15,,83.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,285.12,88,,228.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.28,33.11,,85.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.17,291.6,
INFLUENZA A H1N1 PCR  (MAYO),1887793,CDM,300,RC,87502,HCPCS,Outpatient,,,324.25,194.55,,275.61,85,,220.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,259.5,80.03,,207.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,97.71,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,291.83,90,,233.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,97.71,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,58.43,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,285.34,88,,228.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.18,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,58.43,291.83,
NM PERSANTINE,293819,CDM,250,RC,J1245,HCPCS,Outpatient,,,324.75,194.85,,276.04,85,,220.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,259.9,80.03,,207.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.28,90,,233.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,285.78,88,,228.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.69,292.28,
NIPRIDE ( sodium nitroprusside) 50MG INJ,293125,CDM,250,RC,,,Outpatient,,,325,195,,276.25,85,,221,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.49,32.15,,83.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.1,80.03,,208.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.5,90,,234,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.49,32.15,,83.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.49,32.15,,83.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286,88,,228.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.61,33.11,,86.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.49,292.5,
DRILL 2.1MM CANNULATED,4900021,CDM,278,RC,C1713,HCPCS,Outpatient,,,325,195,,276.25,85,,221,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.49,32.15,,83.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.1,80.03,,208.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.5,90,,234,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.49,32.15,,83.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.49,32.15,,83.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286,88,,228.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.61,33.11,,86.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.49,292.5,
IMMUNOFIXATION W LIGHT CHAINS SERUM MAYO,1886324,CDM,300,RC,86320,HCPCS,Outpatient,,,325,195,,276.25,85,,221,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,260.1,80.03,,208.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,30.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,292.5,90,,234,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,286,88,,228.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.19,292.5,
SUTURE 3.0 VLOC TAPER 6  CV-15 VIOLET,4999101,CDM,270,RC,,,Outpatient,,,325.25,195.15,,276.46,85,,221.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.57,32.15,,83.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.3,80.03,,208.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.73,90,,234.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.57,32.15,,83.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.57,32.15,,83.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.22,88,,228.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.69,33.11,,86.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.57,292.73,
NM PERSANTINE KIT,2932276,CDM,636,RC,J1245,HCPCS,Outpatient,,,325.48,195.29,,276.66,85,,221.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,260.48,80.03,,208.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.93,90,,234.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,3.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,286.42,88,,229.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,3.69,292.93,
INSERTION OF FOLEY CATH,1451702,CDM,450,RC,51702,HCPCS,Outpatient,,,326,195.6,,277.1,85,,221.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.9,80.03,,208.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,293.4,90,,234.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.88,88,,229.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.94,33.11,,86.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.81,293.4,
INSERTION OF FOLEY CATH,351702,CDM,761,RC,51702,HCPCS,Outpatient,,,326,195.6,,277.1,85,,221.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.9,80.03,,208.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,293.4,90,,234.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.88,88,,229.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.94,33.11,,86.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.81,293.4,
INSERTION OF FOLEY CATH,1051702,CDM,761,RC,51702,HCPCS,Outpatient,,,326,195.6,,277.1,85,,221.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.9,80.03,,208.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,293.4,90,,234.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.88,88,,229.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.94,33.11,,86.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.81,293.4,
INSERTION OF FOLEY CATH,1551702,CDM,761,RC,51702,HCPCS,Outpatient,,,326,195.6,,277.1,85,,221.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.9,80.03,,208.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,293.4,90,,234.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.88,88,,229.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.94,33.11,,86.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.81,293.4,
GRASPER EPIX 5MM X 35CM DISPOSALBE,4997501,CDM,270,RC,,,Outpatient,,,328.5,197.1,,279.23,85,,223.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.61,32.15,,84.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.9,80.03,,210.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,295.65,90,,236.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.61,32.15,,84.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,105.61,32.15,,84.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,289.08,88,,231.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.77,33.11,,87.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.61,295.65,
SCISSORS METZENBAUM JAW INSERT,4997502,CDM,270,RC,,,Outpatient,,,328.5,197.1,,279.23,85,,223.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.61,32.15,,84.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.9,80.03,,210.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,295.65,90,,236.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.61,32.15,,84.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,105.61,32.15,,84.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,289.08,88,,231.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.77,33.11,,87.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.61,295.65,
PORT SMALL BOWEL SERIES,22248,CDM,320,RC,74250,HCPCS,Outpatient,,,328.75,197.25,,279.44,85,,223.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.69,32.15,,84.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,263.1,80.03,,210.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,295.88,90,,236.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.69,32.15,,84.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,105.69,32.15,,84.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,289.3,88,,231.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.85,33.11,,87.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.69,295.88,
TRAY LUMBAR PUNCTURE ADULT,492062,CDM,270,RC,,,Outpatient,,,330.25,198.15,,280.71,85,,224.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.18,32.15,,84.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.3,80.03,,211.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.23,90,,237.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.18,32.15,,84.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,106.18,32.15,,84.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,290.62,88,,232.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.35,33.11,,87.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,106.18,297.23,
P/T WOUND >20cm2,3977,CDM,420,RC,97598,HCPCS,Outpatient,,,330.7,198.42,,281.1,85,,224.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.32,32.15,,85.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.66,80.03,,211.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.63,90,,238.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.32,32.15,,85.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,106.32,32.15,,85.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,291.02,88,,232.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.49,33.11,,87.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,106.32,297.63,
KIT SHEATH 8.5FR PERCUTANEOUS INTRO,496594,CDM,270,RC,,,Outpatient,,,330.75,198.45,,281.14,85,,224.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.34,32.15,,85.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.7,80.03,,211.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.68,90,,238.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.34,32.15,,85.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,106.34,32.15,,85.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,291.06,88,,232.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.51,33.11,,87.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,106.34,297.68,
KIT SHEATH 6FR PERCUTANEOUS INTRO,496592,CDM,270,RC,,,Outpatient,,,331,198.6,,281.35,85,,225.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.42,32.15,,85.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.9,80.03,,211.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.9,90,,238.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.42,32.15,,85.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,106.42,32.15,,85.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,291.28,88,,233.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.59,33.11,,87.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,106.42,297.9,
MYCOPHENOLIC ACID SERUM  (MAYO),1882443,CDM,300,RC,80180,HCPCS,Outpatient,,,331.25,198.75,,281.56,85,,225.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,265.1,80.03,,212.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.41,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,298.13,90,,238.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.41,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,6.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,291.5,88,,233.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.5,298.13,
A test used to determine which medications work on bacteria for fungi,1887189,CDM,300,RC,87186,HCPCS,Outpatient,,,331.75,199.05,,281.99,85,,225.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,265.5,80.03,,212.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,298.58,90,,238.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,291.94,88,,233.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.87,298.58,
ARTHROGRAM WRIST RT,22273,CDM,320,RC,73115,HCPCS,Outpatient,,,332.5,199.5,,282.63,85,,226.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.9,32.15,,85.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,266.1,80.03,,212.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,299.25,90,,239.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.9,32.15,,85.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,106.9,32.15,,85.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.6,88,,234.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,110.09,33.11,,88.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,106.9,299.25,
"MALARIA DETECTION, PCR  (MAYO)",1887795,CDM,300,RC,87798,HCPCS,Outpatient,,,333.33,200,,283.33,85,,226.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,266.76,80.03,,213.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,300,90,,240,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,293.33,88,,234.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,300,
ANTIBODY TITER,1887806,CDM,300,RC,86886,HCPCS,Outpatient,,,334.25,200.55,,284.11,85,,227.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,267.5,80.03,,214,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,300.83,90,,240.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,5.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,294.14,88,,235.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.03,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,5.85,300.83,
FINE NEEDLE ASPIRATION TECH FEE,2188172,CDM,310,RC,88172,HCPCS,Outpatient,,,334.25,200.55,,284.11,85,,227.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,267.5,80.03,,214,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,300.83,90,,240.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,56.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,294.14,88,,235.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,56.58,300.83,
TRANSFUSION REACTION IVESTIGATION,2086078,CDM,391,RC,86078,HCPCS,Outpatient,,,334.25,200.55,,284.11,85,,227.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,267.5,80.03,,214,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,300.83,90,,240.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,294.14,88,,235.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.35,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,45,300.83,
AEROSOL OR VAPOR INHALATION BREATHING TX,1494664,CDM,450,RC,94664,HCPCS,Outpatient,,,335.25,201.15,,284.96,85,,227.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.78,32.15,,86.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.3,80.03,,214.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,301.73,90,,241.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.78,32.15,,86.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,107.78,32.15,,86.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.02,88,,236.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111,33.11,,88.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.78,301.73,
Therapy for speech or hearing,3220016,CDM,440,RC,92507,HCPCS,Outpatient,,,335.5,201.3,,285.18,85,,228.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.5,80.03,,214.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,301.95,90,,241.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.24,88,,236.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.08,33.11,,88.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.86,301.95,
CMPLX LAC TRK EACH ADDITIONAL 5CM OR LES,1413102,CDM,450,RC,13102,HCPCS,Outpatient,,,335.5,201.3,,285.18,85,,228.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.5,80.03,,214.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.95,90,,241.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.24,88,,236.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.08,33.11,,88.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.86,301.95,
"CMPLX LAC CM SCALP,ARMS,LEGS,EACH ADD 5C",1413122,CDM,450,RC,13122,HCPCS,Outpatient,,,335.5,201.3,,285.18,85,,228.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.5,80.03,,214.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.95,90,,241.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.24,88,,236.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.08,33.11,,88.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.86,301.95,
"CMPLX LAC FACE,H,F,EACH ADDITIONAL 5CM O",1413133,CDM,450,RC,13133,HCPCS,Outpatient,,,335.5,201.3,,285.18,85,,228.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.5,80.03,,214.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.95,90,,241.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.24,88,,236.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.08,33.11,,88.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.86,301.95,
"CMPLX LAC N,E,E,L EA ADD 5CM OR LESS",1413153,CDM,450,RC,13153,HCPCS,Outpatient,,,335.5,201.3,,285.18,85,,228.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.5,80.03,,214.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.95,90,,241.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,107.86,32.15,,86.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.24,88,,236.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.08,33.11,,88.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.86,301.95,
LAP PORT CLOSURE DEVICE ORANGE,4999918,CDM,270,RC,,,Outpatient,,,336.25,201.75,,285.81,85,,228.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.1,32.15,,86.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,269.1,80.03,,215.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.63,90,,242.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.1,32.15,,86.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.1,32.15,,86.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.9,88,,236.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.33,33.11,,89.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.1,302.63,
COAG FACTOR IX ASSAY P (MAYO),1885318,CDM,300,RC,85250,HCPCS,Outpatient,,,336.5,201.9,,286.03,85,,228.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,269.3,80.03,,215.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,19.42,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,302.85,90,,242.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.42,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.94,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,296.12,88,,236.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.94,302.85,
LARGER COMPLEX SPECIMEN,2188307,CDM,310,RC,88307,HCPCS,Outpatient,,,337.19,202.31,,286.61,85,,229.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,269.85,80.03,,215.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,303.47,90,,242.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,296.73,88,,237.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,133.3,303.47,
CYANIDE ANTIDOTE KIT,293445,CDM,250,RC,,,Outpatient,,,338.1,202.86,,287.39,85,,229.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.7,32.15,,86.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,270.58,80.03,,216.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.29,90,,243.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.7,32.15,,86.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.7,32.15,,86.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,297.53,88,,238.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.94,33.11,,89.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.7,304.29,
ANTENNA EXTERNAL,4999920,CDM,270,RC,,,Outpatient,,,338.25,202.95,,287.51,85,,230.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.75,32.15,,87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,270.7,80.03,,216.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.43,90,,243.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.75,32.15,,87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.75,32.15,,87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,297.66,88,,238.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.99,33.11,,89.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.75,304.43,
S/T SWALLOWING EVAL,322018,CDM,440,RC,92610,HCPCS,Outpatient,,,338.85,203.31,,288.02,85,,230.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.94,32.15,,87.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.18,80.03,,216.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,68.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,304.97,90,,243.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.94,32.15,,87.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,108.94,32.15,,87.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,298.19,88,,238.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.19,33.11,,89.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.94,304.97,
ANESTHESIA STD-BY ON LCL,13040,CDM,370,RC,,,Outpatient,,,339.48,203.69,,288.56,85,,230.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.14,32.15,,87.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.69,80.03,,217.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,305.53,90,,244.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.14,32.15,,87.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,109.14,32.15,,87.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,298.74,88,,238.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.4,33.11,,89.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.14,305.53,
FETAL FIBRONECTIN,1882731,CDM,300,RC,82731,HCPCS,Outpatient,,,339.5,203.7,,288.58,85,,230.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,271.7,80.03,,217.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,65.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,305.55,90,,244.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,65.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,80.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,298.76,88,,239.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.42,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,80.99,305.55,
"CRYPTOCOCCUS AG TITER, LFA SERUM  (MAYO)",1886642,CDM,300,RC,87899,HCPCS,Outpatient,,,339.5,203.7,,288.58,85,,230.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,271.7,80.03,,217.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,305.55,90,,244.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,298.76,88,,239.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.53,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.08,305.55,
US ASPIRATION OF THYROID,24121,CDM,402,RC,60300,HCPCS,Outpatient,,,339.5,203.7,,288.58,85,,230.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.15,32.15,,87.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.7,80.03,,217.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,305.55,90,,244.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.15,32.15,,87.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,109.15,32.15,,87.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,298.76,88,,239.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.41,33.11,,89.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.15,305.55,
EXPAREL(liposomal bupivacaine) 1.3% 10ml,292010,CDM,250,RC,,,Outpatient,,,340,204,,289,85,,231.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.31,32.15,,87.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.1,80.03,,217.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,90,,244.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.31,32.15,,87.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,109.31,32.15,,87.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,299.2,88,,239.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.57,33.11,,90.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.31,306,
APPLY SHORT ARM SPLINT,1429125,CDM,450,RC,29125,HCPCS,Outpatient,,,340.31,204.19,,289.26,85,,231.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.41,32.15,,87.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.35,80.03,,217.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,306.28,90,,245.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.41,32.15,,87.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,109.41,32.15,,87.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,299.47,88,,239.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.68,33.11,,90.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.41,306.28,
Use of water for therapy/exercises,331,CDM,420,RC,97113,HCPCS,Outpatient,,,340.7,204.42,,289.6,85,,231.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.54,32.15,,87.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.66,80.03,,218.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.52,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,306.63,90,,245.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.54,32.15,,87.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,35.52,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,109.54,32.15,,87.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,299.82,88,,239.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.81,33.11,,90.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.54,306.63,
GUIDEWIRE NICORE .038 X 150CM STRAIGHT,4999040,CDM,272,RC,,,Outpatient,,,340.75,204.45,,289.64,85,,231.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.55,32.15,,87.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.7,80.03,,218.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.68,90,,245.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.55,32.15,,87.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,109.55,32.15,,87.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,299.86,88,,239.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.82,33.11,,90.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.55,306.68,
GUIDEWIRE NITINOL STRT-TIP 0.035 NICORE,4999043,CDM,272,RC,,,Outpatient,,,340.75,204.45,,289.64,85,,231.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.55,32.15,,87.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.7,80.03,,218.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.68,90,,245.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.55,32.15,,87.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,109.55,32.15,,87.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,299.86,88,,239.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.82,33.11,,90.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.55,306.68,
HEMOSTAT ARISTA 2.0GM POWDER,4910085,CDM,270,RC,,,Outpatient,,,340.8,204.48,,289.68,85,,231.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.57,32.15,,87.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.74,80.03,,218.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.72,90,,245.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.57,32.15,,87.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,109.57,32.15,,87.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,299.9,88,,239.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.84,33.11,,90.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.57,306.72,
"GLUTATHIONE, B  (MAYO)",1882966,CDM,300,RC,82978,HCPCS,Outpatient,,,341.5,204.9,,290.28,85,,232.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,273.3,80.03,,218.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.75,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,307.35,90,,245.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.75,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,17.92,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,300.52,88,,240.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.46,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,17.92,307.35,
S/T FEEDING/SWALLOWING EVAL 90-Min,3220024,CDM,440,RC,92610,HCPCS,Outpatient,,,341.5,204.9,,290.28,85,,232.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.79,32.15,,87.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,273.3,80.03,,218.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,68.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,307.35,90,,245.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.79,32.15,,87.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,109.79,32.15,,87.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,300.52,88,,240.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.07,33.11,,90.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.79,307.35,
GUIDEWIRE NICORE .038 X 150CM ANGLE TIP,4999041,CDM,272,RC,,,Outpatient,,,342.5,205.5,,291.13,85,,232.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.11,32.15,,88.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.1,80.03,,219.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.25,90,,246.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.11,32.15,,88.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,110.11,32.15,,88.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.4,88,,241.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.4,33.11,,90.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.11,308.25,
SYNERCID ( quinupristin/dalfo) 500MG INJ,296022,CDM,636,RC,J2770,HCPCS,Outpatient,,,343,205.8,,291.55,85,,233.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.5,80.03,,219.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,503.84,102,,,fee schedule,Pays at 102% of CMS APC rate,308.7,90,,246.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,503.84,100,,,fee schedule,Pays at 100% of CMS APC rate,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.84,88,,241.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.57,33.11,,90.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.27,308.7,
"T-CELL GENE, PCR  (MAYO)",1883898,CDM,300,RC,83898,HCPCS,Outpatient,,,343.25,205.95,,291.76,85,,233.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.35,32.15,,88.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.7,80.03,,219.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.93,90,,247.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.35,32.15,,88.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,110.35,32.15,,88.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,302.06,88,,241.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.65,33.11,,90.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.35,308.93,
HSV 1 & 2 QUALITATIVE PCR BLOOD  (MAYO),1884805,CDM,300,RC,87529,HCPCS,Outpatient,,,343.25,205.95,,291.76,85,,233.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,274.7,80.03,,219.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,308.93,90,,247.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,302.06,88,,241.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,308.93,
BOOT MULTIBOOT DELUXE II,314047,CDM,274,RC,L4398,HCPCS,Outpatient,,,344.25,206.55,,292.61,85,,234.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.68,32.15,,88.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,275.5,80.03,,220.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.83,90,,247.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.68,32.15,,88.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,110.68,32.15,,88.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,302.94,88,,242.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.98,33.11,,91.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.68,309.83,
TRAY PERICARDIOCENTESIS,497408,CDM,270,RC,,,Outpatient,,,345.25,207.15,,293.46,85,,234.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.3,80.03,,221.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.73,90,,248.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,303.82,88,,243.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.31,33.11,,91.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,111,310.73,
P/T EVAL DO NOT USE AFTER 12/2106,314,CDM,424,RC,97001,HCPCS,Outpatient,,,345.25,207.15,,293.46,85,,234.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.3,80.03,,221.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.73,90,,248.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,303.82,88,,243.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.31,33.11,,91.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,111,310.73,
O/T EVAL DO NOT USE AFTER 12/2016,3141,CDM,434,RC,97003,HCPCS,Outpatient,,,345.25,207.15,,293.46,85,,234.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.3,80.03,,221.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.73,90,,248.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,303.82,88,,243.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.31,33.11,,91.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,111,310.73,
"CATHERTERIZATION-COMBE, SIMPLE",1453675,CDM,450,RC,,,Outpatient,,,345.25,207.15,,293.46,85,,234.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.3,80.03,,221.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.73,90,,248.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,111,32.15,,88.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,303.82,88,,243.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.31,33.11,,91.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,111,310.73,
TIP SHOWER SOLO SUCTION IRRIGATORS,4999798,CDM,270,RC,,,Outpatient,,,348.75,209.25,,296.44,85,,237.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.1,80.03,,223.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.88,90,,251.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,306.9,88,,245.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.47,33.11,,92.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.12,313.88,
Ultrasound of fetus with limited views,24136,CDM,402,RC,76815,HCPCS,Outpatient,,,349.06,209.44,,296.7,85,,237.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.22,32.15,,89.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.35,80.03,,223.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,314.15,90,,251.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.22,32.15,,89.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,112.22,32.15,,89.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.17,88,,245.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.57,33.11,,92.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.22,314.15,
RETRACTOR ALEXIS O MEDIUM 5-9cm,4980097,CDM,270,RC,,,Outpatient,,,349.25,209.55,,296.86,85,,237.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.28,32.15,,89.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.5,80.03,,223.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.33,90,,251.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.28,32.15,,89.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.28,32.15,,89.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.34,88,,245.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.64,33.11,,92.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.28,314.33,
P/T EVAL HIGH COMPLEXITY,3197163,CDM,424,RC,97163,HCPCS,Outpatient,,,349.38,209.63,,296.97,85,,237.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.33,32.15,,89.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.61,80.03,,223.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,97.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,314.44,90,,251.55,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.33,32.15,,89.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,97.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,112.33,32.15,,89.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.45,88,,245.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.68,33.11,,92.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.33,314.44,
DELINEATOR ADVINCULA 4.0CM ULTEM,499988,CDM,270,RC,,,Outpatient,,,349.75,209.85,,297.29,85,,237.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.9,80.03,,223.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.78,90,,251.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.78,88,,246.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.8,33.11,,92.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.44,314.78,
DELINEATOR ADVINCULA 2.5CM ULTEM,499989,CDM,270,RC,,,Outpatient,,,349.75,209.85,,297.29,85,,237.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.9,80.03,,223.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.78,90,,251.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.78,88,,246.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.8,33.11,,92.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.44,314.78,
DELINEATOR ADVINCULA 3.0CM ULTEM,499990,CDM,270,RC,,,Outpatient,,,349.75,209.85,,297.29,85,,237.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.9,80.03,,223.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.78,90,,251.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.78,88,,246.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.8,33.11,,92.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.44,314.78,
DELINEATOR ADVINCULA 3.5CM ULTEM,499997,CDM,270,RC,,,Outpatient,,,349.75,209.85,,297.29,85,,237.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.9,80.03,,223.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.78,90,,251.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.78,88,,246.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.8,33.11,,92.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.44,314.78,
OTHER CASTING  / STRAPPING PROCEDURE,1429799,CDM,450,RC,29799,HCPCS,Outpatient,,,349.75,209.85,,297.29,85,,237.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.9,80.03,,223.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,314.78,90,,251.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.78,88,,246.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.8,33.11,,92.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.44,314.78,
DENAVIR (penciclovir) 1% 5Gm CREAM,291088,CDM,250,RC,,,Outpatient,,,350,210,,297.5,85,,238,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.11,80.03,,224.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315,90,,252,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308,88,,246.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.89,33.11,,92.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.53,315,
APPLY LONG ARM SPLINT,1429105,CDM,450,RC,29105,HCPCS,Outpatient,,,350.75,210.45,,298.14,85,,238.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.77,32.15,,90.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.71,80.03,,224.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,315.68,90,,252.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.77,32.15,,90.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,112.77,32.15,,90.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308.66,88,,246.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.13,33.11,,92.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.77,315.68,
TUBE TRACH FENESTRATED CUFFED #10,493846,CDM,270,RC,,,Outpatient,,,351.75,211.05,,298.99,85,,239.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.09,32.15,,90.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,281.51,80.03,,225.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.58,90,,253.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.09,32.15,,90.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.09,32.15,,90.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,309.54,88,,247.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.46,33.11,,93.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.09,316.58,
Test to determine how well oxygen moves from the lungs to the blood stream,30075,CDM,460,RC,94010,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.88,33.11,,93.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.49,317.7,
Test to determine how well oxygen moves from the lungs to the blood stream,30372,CDM,460,RC,94010,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.88,33.11,,93.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.49,317.7,
"EPOGEN *NON DIALYSIS* 20,000UNIT INJ",293493,CDM,636,RC,J0885,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.23,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.23,100,,,fee schedule,Pays at 100% of CMS APC rate,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.09,317.7,
US PVR SINGLE,24116,CDM,921,RC,93923,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.88,33.11,,93.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.49,317.7,
US PVR MULTI ARTERIAL,24117,CDM,921,RC,93923,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.88,33.11,,93.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.49,317.7,
US ABI MULTI,24139,CDM,921,RC,93923,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.88,33.11,,93.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.49,317.7,
US ABI SINGLE,24141,CDM,921,RC,93923,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.88,33.11,,93.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.49,317.7,
PORT CYSTOGRAM 3V,22214,CDM,320,RC,74430,HCPCS,Outpatient,,,353.25,211.95,,300.26,85,,240.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.57,32.15,,90.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.71,80.03,,226.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,317.93,90,,254.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.57,32.15,,90.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,113.57,32.15,,90.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.86,88,,248.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.96,33.11,,93.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.57,317.93,
ARCH KOH-EFFICIENT 3.5CM,499985,CDM,270,RC,,,Outpatient,,,353.5,212.1,,300.48,85,,240.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.91,80.03,,226.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.15,90,,254.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,311.08,88,,248.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.04,33.11,,93.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.65,318.15,
ARCH KOH-EFFICIENT 2.5CM,499995,CDM,270,RC,,,Outpatient,,,353.5,212.1,,300.48,85,,240.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.91,80.03,,226.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.15,90,,254.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,311.08,88,,248.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.04,33.11,,93.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.65,318.15,
ARCH KOH-EFFICIENT 3.0CM,499998,CDM,270,RC,,,Outpatient,,,353.5,212.1,,300.48,85,,240.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.91,80.03,,226.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.15,90,,254.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.65,32.15,,90.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,311.08,88,,248.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.04,33.11,,93.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.65,318.15,
"EBV, MOLECULAR DETECTION QT PCR  (MAYO)",1882683,CDM,300,RC,87799,HCPCS,Outpatient,,,354.63,212.78,,301.44,85,,241.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.01,32.15,,91.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,283.81,80.03,,227.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,43.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,319.17,90,,255.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.01,32.15,,91.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,114.01,32.15,,91.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,312.07,88,,249.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.42,33.11,,93.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.01,319.17,
"RAST, SOUTHEASTERN PANEL  (MAYO)",1886014,CDM,300,RC,82785,HCPCS,Outpatient,,,354.75,212.85,,301.54,85,,241.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,283.91,80.03,,227.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,16.78,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,319.28,90,,255.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,16.78,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,20.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,312.18,88,,249.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.71,319.28,
ATROVENT HFA (ipratropium) INHALER,292099,CDM,250,RC,,,Outpatient,,,355,213,,301.75,85,,241.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.11,80.03,,227.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.5,90,,255.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,312.4,88,,249.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.54,33.11,,94.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.13,319.5,
Serial radiologic examination of the abdomen,22132,CDM,320,RC,74022,HCPCS,Outpatient,,,355,213,,301.75,85,,241.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.11,80.03,,227.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,319.5,90,,255.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,312.4,88,,249.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.54,33.11,,94.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.13,319.5,
US HEMATOMA OR MUSCLE,24095,CDM,402,RC,76881,HCPCS,Outpatient,,,355,213,,301.75,85,,241.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.11,80.03,,227.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,319.5,90,,255.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,114.13,32.15,,91.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,312.4,88,,249.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.54,33.11,,94.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.13,319.5,
DO NOT USE,322027,CDM,440,RC,92510,HCPCS,Outpatient,,,355.25,213.15,,301.96,85,,241.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.21,32.15,,91.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.31,80.03,,227.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.73,90,,255.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.21,32.15,,91.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.21,32.15,,91.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,312.62,88,,250.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.62,33.11,,94.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.21,319.73,
METHADONE CONFIRMATION   (MAYO),1883840,CDM,300,RC,80358,HCPCS,Outpatient,,,355.43,213.26,,302.12,85,,241.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,284.45,80.03,,227.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.89,90,,255.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,20.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,312.78,88,,250.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.15,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.53,319.89,
STRESS TEST OCT,6015,CDM,920,RC,59020,HCPCS,Outpatient,,,356,213.6,,302.6,85,,242.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.45,32.15,,91.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.91,80.03,,227.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,170.77,102,,,fee schedule,Pays at 102% of CMS APC rate,320.4,90,,256.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.45,32.15,,91.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.77,100,,,fee schedule,Pays at 100% of CMS APC rate,114.45,32.15,,91.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,313.28,88,,250.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,117.87,33.11,,94.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.45,320.4,
US ASPIRATION OF BREAST MULTIPLE,24129,CDM,761,RC,19001,HCPCS,Outpatient,,,357.25,214.35,,303.66,85,,242.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.86,32.15,,91.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,285.91,80.03,,228.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.53,90,,257.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.86,32.15,,91.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.86,32.15,,91.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.38,88,,251.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.29,33.11,,94.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.86,321.53,
FLUORO FOR CENTRAL VENOUS ACCESS,22163,CDM,320,RC,77001,HCPCS,Outpatient,,,357.75,214.65,,304.09,85,,243.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.31,80.03,,229.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.98,90,,257.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.82,88,,251.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.45,33.11,,94.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.02,321.98,
FLUORO GUIDE W NEEDLE PLACEMENT,22165,CDM,320,RC,77002,HCPCS,Outpatient,,,357.75,214.65,,304.09,85,,243.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.31,80.03,,229.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.98,90,,257.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.82,88,,251.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.45,33.11,,94.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.02,321.98,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",22190,CDM,320,RC,76000,HCPCS,Outpatient,,,357.75,214.65,,304.09,85,,243.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.31,80.03,,229.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,321.98,90,,257.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.82,88,,251.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.45,33.11,,94.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.02,321.98,
OR FLUORO LOC NEEDLE BX,22192,CDM,320,RC,77002,HCPCS,Outpatient,,,357.75,214.65,,304.09,85,,243.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.31,80.03,,229.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.98,90,,257.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.82,88,,251.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.45,33.11,,94.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.02,321.98,
CT BONE DENSITY STUDY,26060,CDM,320,RC,77078,HCPCS,Outpatient,,,357.75,214.65,,304.09,85,,243.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.31,80.03,,229.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,321.98,90,,257.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,115.02,32.15,,92.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.82,88,,251.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.45,33.11,,94.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.02,321.98,
COAG FACTOR XI ASSAY P (MAYO),1885316,CDM,300,RC,85270,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.25,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.25,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,22.52,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,22.52,322.2,
IF ADDITIONAL (MAYO),2188388,CDM,310,RC,88350,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,61.42,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.42,322.2,
OR PYELOGRAM RETRO,22376,CDM,320,RC,74420,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.53,33.11,,94.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.1,322.2,
OR URETHROGRAM,2274450,CDM,320,RC,74450,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.53,33.11,,94.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.1,322.2,
INVANZ (ertapenem) 1GM VIAL,292120,CDM,636,RC,J1335,HCPCS,Outpatient,,,360,216,,306,85,,244.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,288.11,80.03,,230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324,90,,259.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,360,,,,Other,Not Separately reimbursable,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,316.8,88,,253.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.19,324,
NM ADENOSINE 30/ML,293156,CDM,636,RC,J0153,HCPCS,Outpatient,,,360,216,,306,85,,244.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,288.11,80.03,,230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324,90,,259.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,360,,,,Other,Not Separately reimbursable,0.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,316.8,88,,253.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.56,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.54,324,
LASER SHIELD 6.0MM X 9.0MM 27FR,49900,CDM,270,RC,,,Outpatient,,,360.25,216.15,,306.21,85,,244.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.82,32.15,,92.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,288.31,80.03,,230.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.23,90,,259.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.82,32.15,,92.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,360.25,,,,Other,Not Separately reimbursable,115.82,32.15,,92.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,317.02,88,,253.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.28,33.11,,95.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.82,324.23,
LASER SHIELD 6.5MM X 10.0MM 27FR,49901,CDM,270,RC,,,Outpatient,,,360.25,216.15,,306.21,85,,244.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.82,32.15,,92.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,288.31,80.03,,230.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.23,90,,259.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.82,32.15,,92.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,360.25,,,,Other,Not Separately reimbursable,115.82,32.15,,92.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,317.02,88,,253.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.28,33.11,,95.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.82,324.23,
Radiologic examination of the shoulder,22454,CDM,320,RC,73030,HCPCS,Outpatient,,,360.94,216.56,,306.8,85,,245.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,116.04,32.15,,92.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,288.86,80.03,,231.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,324.85,90,,259.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,116.04,32.15,,92.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,116.04,32.15,,92.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,317.63,88,,254.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.51,33.11,,95.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,116.04,324.85,
PAD QUICK PACE (EXT),491910,CDM,270,RC,,,Outpatient,,,363,217.8,,308.55,85,,246.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,290.51,80.03,,232.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.7,90,,261.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,363,,,,Other,Not Separately reimbursable,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,319.44,88,,255.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,120.19,33.11,,96.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,116.7,326.7,
RCAI MULTIPODUS SPLINT,444,CDM,274,RC,L4398,HCPCS,Outpatient,,,363,217.8,,308.55,85,,246.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,290.51,80.03,,232.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.7,90,,261.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,319.44,88,,255.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,120.19,33.11,,96.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,116.7,326.7,
SEXUAL ASSAULT SCREEN MAYO,1880108,CDM,300,RC,80301,HCPCS,Outpatient,,,363,217.8,,308.55,85,,246.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,290.51,80.03,,232.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.7,90,,261.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,363,,,,Other,Not Separately reimbursable,116.7,32.15,,93.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,319.44,88,,255.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,120.19,33.11,,96.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,116.7,326.7,
Test of tissues for diagnosis of abnormalities,2188306,CDM,310,RC,88305,HCPCS,Outpatient,,,363.75,218.25,,309.19,85,,247.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,291.11,80.03,,232.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,327.38,90,,261.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,320.1,88,,256.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,65.88,327.38,
PATH EXAM LGE/MUL SM TECH  (CSI),1888307,CDM,310,RC,88307,HCPCS,Outpatient,,,364.75,218.85,,310.04,85,,248.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,291.91,80.03,,233.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,328.28,90,,262.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,320.98,88,,256.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,133.3,328.28,
Therapy for speech or hearing,322110,CDM,440,RC,92507,HCPCS,Outpatient,,,365,219,,310.25,85,,248.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.35,32.15,,93.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.11,80.03,,233.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,328.5,90,,262.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.35,32.15,,93.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,117.35,32.15,,93.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.2,88,,256.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,120.85,33.11,,96.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.35,328.5,
Blood test to assist with diagnosis,2188323,CDM,310,RC,88313,HCPCS,Outpatient,,,365.25,219.15,,310.46,85,,248.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,292.31,80.03,,233.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,328.73,90,,262.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,321.42,88,,257.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,328.73,
MATTHOVER SINGLE USE,49008,CDM,270,RC,,,Outpatient,,,365.5,219.3,,310.68,85,,248.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.51,80.03,,234.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.95,90,,263.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.5,,,,Other,Not Separately reimbursable,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.64,88,,257.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.02,33.11,,96.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.51,328.95,
BUR FLUTED 6MM ROUND,49720,CDM,270,RC,,,Outpatient,,,365.5,219.3,,310.68,85,,248.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.51,80.03,,234.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.95,90,,263.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.5,,,,Other,Not Separately reimbursable,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.64,88,,257.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.02,33.11,,96.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.51,328.95,
BUR PRECISION DIAMOND 6MM ROUND,49721,CDM,270,RC,,,Outpatient,,,365.5,219.3,,310.68,85,,248.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.51,80.03,,234.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.95,90,,263.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.5,,,,Other,Not Separately reimbursable,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.64,88,,257.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.02,33.11,,96.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.51,328.95,
BUR DIAMOND 3MM ROUND,49722,CDM,270,RC,,,Outpatient,,,365.5,219.3,,310.68,85,,248.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.51,80.03,,234.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.95,90,,263.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.5,,,,Other,Not Separately reimbursable,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.64,88,,257.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.02,33.11,,96.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.51,328.95,
PORT PYELOGRAM RETO,22238,CDM,320,RC,74420,HCPCS,Outpatient,,,365.5,219.3,,310.68,85,,248.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.51,80.03,,234.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,328.95,90,,263.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,117.51,32.15,,94.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.64,88,,257.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.02,33.11,,96.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.51,328.95,
COPEPTIN proAVP (MAYO),1884891,CDM,300,RC,84588,HCPCS,Outpatient,,,366.38,219.83,,311.42,85,,249.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,293.21,80.03,,234.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,34.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,329.74,90,,263.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,42.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,322.41,88,,257.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,42.69,329.74,
SKELETAL TRACTION INC PIN,49505,CDM,270,RC,,,Outpatient,,,366.5,219.9,,311.53,85,,249.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.31,80.03,,234.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,329.85,90,,263.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.5,,,,Other,Not Separately reimbursable,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,322.52,88,,258.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.35,33.11,,97.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.83,329.85,
CONTRL POST/NASL HEMORR -SUBSEQUNET,1430906,CDM,450,RC,30906,HCPCS,Outpatient,,,366.5,219.9,,311.53,85,,249.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.31,80.03,,234.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,329.85,90,,263.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,322.52,88,,258.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.35,33.11,,97.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.83,329.85,
CLSURE LAC VEST < 2.5 CM,1440830,CDM,450,RC,40830,HCPCS,Outpatient,,,366.5,219.9,,311.53,85,,249.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.31,80.03,,234.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,329.85,90,,263.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,322.52,88,,258.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.35,33.11,,97.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.83,329.85,
I & D ABSCESS PERITONSILLAR ABSCESS,1442700,CDM,450,RC,42700,HCPCS,Outpatient,,,366.5,219.9,,311.53,85,,249.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.31,80.03,,234.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,329.85,90,,263.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,322.52,88,,258.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.35,33.11,,97.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.83,329.85,
CULDOCENTESIS,1457450,CDM,450,RC,57020,HCPCS,Outpatient,,,366.5,219.9,,311.53,85,,249.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.31,80.03,,234.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4443.7,102,,,fee schedule,Pays at 102% of CMS APC rate,329.85,90,,263.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4443.7,100,,,fee schedule,Pays at 100% of CMS APC rate,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,322.52,88,,258.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.35,33.11,,97.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.83,329.85,
MYRINCOTOMY INCLUDING ASP AND/OR INFLATI,1469420,CDM,450,RC,69420,HCPCS,Outpatient,,,366.5,219.9,,311.53,85,,249.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.31,80.03,,234.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,329.85,90,,263.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,117.83,32.15,,94.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,322.52,88,,258.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.35,33.11,,97.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.83,329.85,
SET FEEDING SPIKE 1000ML FLUSH KANGAROO,493829,CDM,270,RC,,,Outpatient,,,367.25,220.35,,312.16,85,,249.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.07,32.15,,94.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.91,80.03,,235.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.53,90,,264.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.07,32.15,,94.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,367.25,,,,Other,Not Separately reimbursable,118.07,32.15,,94.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,323.18,88,,258.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.6,33.11,,97.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.07,330.53,
SCOLIOSIS STUDY 2 VIEW,2272082,CDM,320,RC,72082,HCPCS,Outpatient,,,368,220.8,,312.8,85,,250.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.31,32.15,,94.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,294.51,80.03,,235.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,331.2,90,,264.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.31,32.15,,94.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,118.31,32.15,,94.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,323.84,88,,259.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.84,33.11,,97.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.31,331.2,
BADGER 8 MM DRILL BIT CANNULATED,4908599,CDM,272,RC,,,Outpatient,,,369.75,221.85,,314.29,85,,251.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.87,32.15,,95.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.91,80.03,,236.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,332.78,90,,266.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.87,32.15,,95.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.75,,,,Other,Not Separately reimbursable,118.87,32.15,,95.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.38,88,,260.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,122.42,33.11,,97.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.87,332.78,
Echo with doppler,24124,CDM,480,RC,93320,HCPCS,Outpatient,,,369.75,221.85,,314.29,85,,251.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.87,32.15,,95.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.91,80.03,,236.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,332.78,90,,266.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.87,32.15,,95.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.75,,,,Other,Not Separately reimbursable,118.87,32.15,,95.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.38,88,,260.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,122.42,33.11,,97.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.87,332.78,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,24053,CDM,402,RC,76801,HCPCS,Outpatient,,,370,222,,314.5,85,,251.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.96,32.15,,95.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,296.11,80.03,,236.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,333,90,,266.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.96,32.15,,95.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,118.96,32.15,,95.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.6,88,,260.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,122.51,33.11,,98.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.96,333,
CHROMOSOME FRAGILE X SYNDROME  (MAYO),1888262,CDM,310,RC,88248,HCPCS,Outpatient,,,370.5,222.3,,314.93,85,,251.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,217.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,296.51,80.03,,237.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,176.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,333.45,90,,266.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,217.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,176.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,217.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,326.04,88,,260.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,224.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,217.76,333.45,
BLS NONEMERGENCY TRANSPORT,530320,CDM,540,RC,A0428,HCPCS,Outpatient,,,370.65,222.39,,315.05,85,,252.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,119.16,32.15,,95.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,296.63,80.03,,237.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.59,90,,266.87,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,119.16,32.15,,95.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,119.16,32.15,,95.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.17,88,,260.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,122.72,33.11,,98.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,119.16,333.59,
BLS NONEMERGENCY TRANSPORT,530428,CDM,540,RC,A0428,HCPCS,Outpatient,,,370.65,222.39,,315.05,85,,252.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,119.16,32.15,,95.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,296.63,80.03,,237.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.59,90,,266.87,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,119.16,32.15,,95.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,119.16,32.15,,95.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.17,88,,260.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,122.72,33.11,,98.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,119.16,333.59,
4 or more views,22204,CDM,320,RC,71048,HCPCS,Outpatient,,,371.8,223.08,,316.03,85,,252.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,119.53,32.15,,95.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,297.55,80.03,,238.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,334.62,90,,267.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,119.53,32.15,,95.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,119.53,32.15,,95.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,327.18,88,,261.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,123.1,33.11,,98.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,119.53,334.62,
PROSTIN VR (alprostadil) 500mcg inj PED,296094,CDM,636,RC,J0270,HCPCS,Outpatient,,,373,223.8,,317.05,85,,253.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,119.92,32.15,,95.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,298.51,80.03,,238.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,335.7,90,,268.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,119.92,32.15,,95.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,119.92,32.15,,95.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,328.24,88,,262.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,123.5,33.11,,98.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,119.92,335.7,
Radiologic examination of the shoulder,22362,CDM,320,RC,73030,HCPCS,Outpatient,,,373.44,224.06,,317.42,85,,253.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,120.06,32.15,,96.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,298.86,80.03,,239.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,336.1,90,,268.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,120.06,32.15,,96.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,120.06,32.15,,96.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,328.63,88,,262.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,123.65,33.11,,98.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120.06,336.1,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1883509,CDM,300,RC,83516,HCPCS,Outpatient,,,374.25,224.55,,318.11,85,,254.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,299.51,80.03,,239.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,336.83,90,,269.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,13.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,329.34,88,,263.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.45,336.83,
"CHROMO ANALYSIS; 5 CELLS, 1 KARO W BAND",2188282,CDM,300,RC,88261,HCPCS,Outpatient,,,374.5,224.7,,318.33,85,,254.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,222.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,299.71,80.03,,239.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,269.62,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,337.05,90,,269.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,222.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,269.62,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,222.24,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,329.56,88,,263.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,228.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,222.24,337.05,
"ELASTASE, STOOL  (MAYO)",1882649,CDM,300,RC,83519,HCPCS,Outpatient,,,374.75,224.85,,318.54,85,,254.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,299.91,80.03,,239.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,337.28,90,,269.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,329.78,88,,263.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,337.28,
BRACE BLEDSOE,49501,CDM,270,RC,,,Outpatient,,,375,225,,318.75,85,,255,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,120.56,32.15,,96.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,300.11,80.03,,240.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.5,90,,270,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,120.56,32.15,,96.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,120.56,32.15,,96.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,330,88,,264,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,124.16,33.11,,99.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120.56,337.5,
GROWTH HORMONE RELEASING HORMONE  (MAYO),1882241,CDM,300,RC,83519,HCPCS,Outpatient,,,375,225,,318.75,85,,255,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,300.11,80.03,,240.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,337.5,90,,270,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,330,88,,264,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,337.5,
VALIUM (RECTAL-DIAZEPAM) 10MG,293544,CDM,636,RC,J3360,HCPCS,Outpatient,,,375,225,,318.75,85,,255,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,300.11,80.03,,240.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.5,90,,270,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,330,88,,264,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.48,337.5,
VIBATIV (telavancin) 750MG VIAL,296426,CDM,636,RC,J3095,HCPCS,Outpatient,,,375,225,,318.75,85,,255,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,120.56,32.15,,96.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,300.11,80.03,,240.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.29,102,,,fee schedule,Pays at 102% of CMS APC rate,337.5,90,,270,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,120.56,32.15,,96.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7.29,100,,,fee schedule,Pays at 100% of CMS APC rate,120.56,32.15,,96.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,330,88,,264,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,124.16,33.11,,99.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120.56,337.5,
Therapy for speech or hearing,322013,CDM,440,RC,92507,HCPCS,Outpatient,,,376.25,225.75,,319.81,85,,255.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,120.96,32.15,,96.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.11,80.03,,240.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,338.63,90,,270.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,120.96,32.15,,96.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,120.96,32.15,,96.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.1,88,,264.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,124.58,33.11,,99.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120.96,338.63,
Radiologic examination of the heel,22383,CDM,320,RC,73650,HCPCS,Outpatient,,,378.2,226.92,,321.47,85,,257.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,121.59,32.15,,97.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,302.67,80.03,,242.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,340.38,90,,272.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,121.59,32.15,,97.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,121.59,32.15,,97.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.82,88,,266.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,125.22,33.11,,100.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,121.59,340.38,
Radiologic examination of the knee with 1 or 2 views,22399,CDM,320,RC,73560,HCPCS,Outpatient,,,378.2,226.92,,321.47,85,,257.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,121.59,32.15,,97.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,302.67,80.03,,242.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,340.38,90,,272.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,121.59,32.15,,97.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,121.59,32.15,,97.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.82,88,,266.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,125.22,33.11,,100.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,121.59,340.38,
VALIUM (RECTAL-DIASTAT) 2.5MG GEL,293454,CDM,636,RC,J3360,HCPCS,Outpatient,,,380,228,,323,85,,258.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,304.11,80.03,,243.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342,90,,273.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,7.48,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,334.4,88,,267.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.7,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.48,342,
NORWALK LIKE VIRUS PCR (MAYO),1887449,CDM,300,RC,87798,HCPCS,Outpatient,,,381,228.6,,323.85,85,,259.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,304.91,80.03,,243.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,342.9,90,,274.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,335.28,88,,268.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,342.9,
SCOLIOSIS STUDY COMPLETE,22038,CDM,320,RC,72083,HCPCS,Outpatient,,,381,228.6,,323.85,85,,259.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,304.91,80.03,,243.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,342.9,90,,274.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,335.28,88,,268.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.15,33.11,,100.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,122.49,342.9,
US OB FOLLOW-UP PER FETUS,24137,CDM,402,RC,76816,HCPCS,Outpatient,,,381,228.6,,323.85,85,,259.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,304.91,80.03,,243.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,342.9,90,,274.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,335.28,88,,268.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.15,33.11,,100.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,122.49,342.9,
Fetal biophysical profile without non-stress test,24142,CDM,402,RC,76819,HCPCS,Outpatient,,,381,228.6,,323.85,85,,259.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,304.91,80.03,,243.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,342.9,90,,274.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,122.49,32.15,,97.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,335.28,88,,268.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.15,33.11,,100.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,122.49,342.9,
CUBE CARE POLAR,4999919,CDM,270,RC,,,Outpatient,,,381.5,228.9,,324.28,85,,259.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.65,32.15,,98.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,305.31,80.03,,244.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.35,90,,274.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.65,32.15,,98.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,122.65,32.15,,98.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,335.72,88,,268.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.31,33.11,,101.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,122.65,343.35,
CELL SAVER SUPPLIES & MATERAILS,490051,CDM,272,RC,99070,HCPCS,Outpatient,,,383,229.8,,325.55,85,,260.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,123.13,32.15,,98.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,306.51,80.03,,245.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,344.7,90,,275.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,123.13,32.15,,98.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,123.13,32.15,,98.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.04,88,,269.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.81,33.11,,101.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,123.13,344.7,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",290081,CDM,260,RC,96365,HCPCS,Outpatient,,,383.76,230.26,,326.2,85,,260.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,123.38,32.15,,98.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.12,80.03,,245.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,345.38,90,,276.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,123.38,32.15,,98.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,123.38,32.15,,98.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.71,88,,270.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,127.06,33.11,,101.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,123.38,345.38,
DO NOT USE,322120,CDM,440,RC,92506,HCPCS,Outpatient,,,384,230.4,,326.4,85,,261.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.32,80.03,,245.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.6,90,,276.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.92,88,,270.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,127.14,33.11,,101.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,123.46,345.6,
INVANZ  (ertapenem ) 1GM / NS 50ML PB,292121,CDM,636,RC,J1335,HCPCS,Outpatient,,,385,231,,327.25,85,,261.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,308.12,80.03,,246.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.5,90,,277.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,338.8,88,,271.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.19,346.5,
INVANZ  (ertapenem ) 500MG/NS 50ML PB,293884,CDM,636,RC,J1335,HCPCS,Outpatient,,,385,231,,327.25,85,,261.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,308.12,80.03,,246.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.5,90,,277.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,13.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,338.8,88,,271.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.59,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,13.19,346.5,
Radiologic examination of the knee with 3 views,22202,CDM,320,RC,73562,HCPCS,Outpatient,,,386,231.6,,328.1,85,,262.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308.92,80.03,,247.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,347.4,90,,277.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,339.68,88,,271.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,127.8,33.11,,102.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,124.1,347.4,
IVP,1474400,CDM,450,RC,74400,HCPCS,Outpatient,,,387,232.2,,328.95,85,,263.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,124.42,32.15,,99.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,309.72,80.03,,247.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,348.3,90,,278.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,124.42,32.15,,99.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,124.42,32.15,,99.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,340.56,88,,272.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,128.14,33.11,,102.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,124.42,348.3,
"H PYLORI + CLARI RESIST, PCR, F (MAYO)",1887339,CDM,300,RC,87798,HCPCS,Outpatient,,,387.55,232.53,,329.42,85,,263.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.16,80.03,,248.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,348.8,90,,279.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,341.04,88,,272.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,348.8,
PATHOLOGY -OUTSIDE SLIDE INTERPRETATION,2188321,CDM,310,RC,88321,HCPCS,Outpatient,,,388.25,232.95,,330.01,85,,264.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,80.03,,248.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,349.43,90,,279.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,59.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,341.66,88,,273.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,59.02,349.43,
PELVIS 4 VIEWS,22522,CDM,320,RC,73503,HCPCS,Outpatient,,,388.25,232.95,,330.01,85,,264.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,124.82,32.15,,99.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.72,80.03,,248.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,349.43,90,,279.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,124.82,32.15,,99.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,124.82,32.15,,99.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,341.66,88,,273.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,128.55,33.11,,102.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,124.82,349.43,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",24022,CDM,402,RC,76882,HCPCS,Outpatient,,,388.25,232.95,,330.01,85,,264.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,124.82,32.15,,99.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.72,80.03,,248.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,349.43,90,,279.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,124.82,32.15,,99.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,124.82,32.15,,99.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,341.66,88,,273.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,128.55,33.11,,102.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,124.82,349.43,
TRAY EPIDURAL 17G X 3 1/2,492100,CDM,270,RC,,,Outpatient,,,390.63,234.38,,332.04,85,,265.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,125.59,32.15,,100.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,312.62,80.03,,250.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.57,90,,281.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,125.59,32.15,,100.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,125.59,32.15,,100.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,343.75,88,,275,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,129.34,33.11,,103.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,125.59,351.57,
VARICELLA ZOSTER DNA QT PCR  (MAYO),1882207,CDM,300,RC,87798,HCPCS,Outpatient,,,391.5,234.9,,332.78,85,,266.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,313.32,80.03,,250.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,352.35,90,,281.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,344.52,88,,275.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,352.35,
THROMBIN (bovine thrombin) 20K U TOPICAL,296072,CDM,250,RC,,,Outpatient,,,393,235.8,,334.05,85,,267.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,126.35,32.15,,101.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.52,80.03,,251.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353.7,90,,282.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,126.35,32.15,,101.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,126.35,32.15,,101.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,345.84,88,,276.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.12,33.11,,104.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,126.35,353.7,
TAMIFLU (oseltamivir) 6MG/ML SUSP 60ML,292337,CDM,250,RC,,,Outpatient,,,393.67,236.2,,334.62,85,,267.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,126.56,32.15,,101.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.05,80.03,,252.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,354.3,90,,283.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,126.56,32.15,,101.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,126.56,32.15,,101.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,346.43,88,,277.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.34,33.11,,104.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,126.56,354.3,
PCA3  ASSAY  (MAYO),1882686,CDM,300,RC,81313,HCPCS,Outpatient,,,394.25,236.55,,335.11,85,,268.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,126.75,32.15,,101.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.52,80.03,,252.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.15,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,354.83,90,,283.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,126.75,32.15,,101.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.15,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,126.75,32.15,,101.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,346.94,88,,277.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.54,33.11,,104.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,126.75,354.83,
PACEMAKER CHG PER DAY,497501,CDM,275,RC,,,Outpatient,,,395,237,,335.75,85,,268.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,126.99,32.15,,101.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,316.12,80.03,,252.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,355.5,90,,284.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,126.99,32.15,,101.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,126.99,32.15,,101.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,347.6,88,,278.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.78,33.11,,104.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,126.99,355.5,
INITIAL HAND HELD NEBULIZER,30130,CDM,410,RC,94640,HCPCS,Outpatient,,,395.45,237.27,,336.13,85,,268.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,127.14,32.15,,101.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,316.48,80.03,,253.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,355.91,90,,284.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,127.14,32.15,,101.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,127.14,32.15,,101.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,348,88,,278.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.93,33.11,,104.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,127.14,355.91,
INITIAL MDI THERAPY,30241,CDM,410,RC,94640,HCPCS,Outpatient,,,395.45,237.27,,336.13,85,,268.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,127.14,32.15,,101.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,316.48,80.03,,253.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,355.91,90,,284.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,127.14,32.15,,101.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,127.14,32.15,,101.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,348,88,,278.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.93,33.11,,104.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,127.14,355.91,
FLOVENT HFA 220MCG INHALER,292032,CDM,250,RC,,,Outpatient,,,396.5,237.9,,337.03,85,,269.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,127.47,32.15,,101.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,317.32,80.03,,253.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,356.85,90,,285.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,127.47,32.15,,101.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.47,32.15,,101.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,348.92,88,,279.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,131.28,33.11,,105.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,127.47,356.85,
MENS LIBERTY EXTERNAL CATH,49561,CDM,270,RC,,,Outpatient,,,396.88,238.13,,337.35,85,,269.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,127.6,32.15,,102.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,317.62,80.03,,254.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357.19,90,,285.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,127.6,32.15,,102.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.6,32.15,,102.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.25,88,,279.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,131.41,33.11,,105.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,127.6,357.19,
"ALPHA FETOPROTEIN, MATERNAL  (MAYO)",1886245,CDM,300,RC,81511,HCPCS,Outpatient,,,397.5,238.5,,337.88,85,,270.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,318.12,80.03,,254.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,156.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,357.75,90,,286.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,156.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,122.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,349.8,88,,279.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,122.8,357.75,
BED VQUE,49097,CDM,270,RC,,,Outpatient,,,397.75,238.65,,338.09,85,,270.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,127.88,32.15,,102.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.32,80.03,,254.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357.98,90,,286.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,127.88,32.15,,102.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.88,32.15,,102.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.02,88,,280.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,131.7,33.11,,105.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,127.88,357.98,
ADALIMUMAB QN REFLEX AB SERUM (MAYO),1883914,CDM,300,RC,80145,HCPCS,Outpatient,,,398.02,238.81,,338.32,85,,270.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,318.54,80.03,,254.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,39.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,358.22,90,,286.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,30.86,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,350.26,88,,280.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.79,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.86,358.22,
US AMNIOCENTESIS,24028,CDM,402,RC,76946,HCPCS,Outpatient,,,398.25,238.95,,338.51,85,,270.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,128.04,32.15,,102.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.72,80.03,,254.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.43,90,,286.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,128.04,32.15,,102.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,128.04,32.15,,102.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.46,88,,280.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,131.86,33.11,,105.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,128.04,358.43,
A test used to determine which medications work on bacteria for fungi,1887109,CDM,300,RC,87186,HCPCS,Outpatient,,,398.44,239.06,,338.67,85,,270.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,318.87,80.03,,255.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,8.82,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,358.6,90,,286.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8.82,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,10.87,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,350.63,88,,280.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,11.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.87,358.6,
KIT TRAMA 8.5FR,490075,CDM,270,RC,,,Outpatient,,,398.75,239.25,,338.94,85,,271.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,128.2,32.15,,102.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,319.12,80.03,,255.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.88,90,,287.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,128.2,32.15,,102.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,128.2,32.15,,102.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.9,88,,280.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,132.03,33.11,,105.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,128.2,358.88,
GALLBLADDER,22089,CDM,320,RC,74290,HCPCS,Outpatient,,,399.05,239.43,,339.19,85,,271.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,128.29,32.15,,102.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,319.36,80.03,,255.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,359.15,90,,287.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,128.29,32.15,,102.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,128.29,32.15,,102.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,351.16,88,,280.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,132.13,33.11,,105.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,128.29,359.15,
"New patient office or other outpatient visit, typically 30 min",99203,CDM,510,RC,99203,HCPCS,Outpatient,,,400.63,240.38,,340.54,85,,272.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,128.8,32.15,,103.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,320.62,80.03,,256.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.57,90,,288.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,128.8,32.15,,103.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,128.8,32.15,,103.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.55,88,,282.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,132.65,33.11,,106.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,128.8,360.57,
HEPARIN PF4 IGG AB (HIT)  (MAYO),1886021,CDM,300,RC,86022,HCPCS,Outpatient,,,401.25,240.75,,341.06,85,,272.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,321.12,80.03,,256.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,361.13,90,,288.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,353.1,88,,282.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.09,361.13,
VIGAMOX (moxifloxacin) OPHTH SOL 3 ML,291036,CDM,250,RC,,,Outpatient,,,401.64,240.98,,341.39,85,,273.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,129.13,32.15,,103.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.43,80.03,,257.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.48,90,,289.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,129.13,32.15,,103.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,129.13,32.15,,103.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.44,88,,282.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,132.98,33.11,,106.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,129.13,361.48,
SURFIT LOOP OSTOMY SYSTEM 4,493215,CDM,270,RC,,,Outpatient,,,405.75,243.45,,344.89,85,,275.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.45,32.15,,104.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,324.72,80.03,,259.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.18,90,,292.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.45,32.15,,104.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.45,32.15,,104.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.06,88,,285.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.34,33.11,,107.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.45,365.18,
DO NOT USE,322010,CDM,440,RC,92510,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T EVAL COCHLEAR IMPLANT Pt. <7 years,3292601,CDM,440,RC,92601,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T Reasses COCH. IMPLANT Pt. <7 years,3292602,CDM,440,RC,92602,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T EVAL COCHLEAR IMPLANT Pt. >7 years,3292603,CDM,440,RC,92603,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T Reasses COCH. IMPLANT Pt. >7 years,3292604,CDM,440,RC,92604,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T EVAL NON-SPEECH DEVICE,3292605,CDM,440,RC,92605,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,85.05,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.05,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
"S/T TREATMENT, NON-SPEECH DEVICE",3292606,CDM,440,RC,92606,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,67.64,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.64,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T EVAL SPEECH GENERATING DEVICE,3292607,CDM,440,RC,92607,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,120.16,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.16,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
"S/T EVAL AUDITORY REHAB STATUS, 1HR",3292626,CDM,440,RC,92626,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
"S/T EVAL AUDITORY REHAB,  Ea  ADD 15 MIN",3292627,CDM,440,RC,92627,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T AUDITORY REHAB; PRE-LINGUAL LOSS,3292630,CDM,440,RC,92630,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T AUDITORY REHAB; POST-LINGUAL LOSS,3292633,CDM,440,RC,92633,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T EVALUATION OF APHASIA,3296105,CDM,440,RC,96105,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,95.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
Childhood test to screen for developmental disabilities,3296110,CDM,440,RC,96110,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T DEVELOPMENTAL TESTING W/ STNDRD FORM,3296111,CDM,440,RC,96111,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
S/T COGNITIVE TESTING W/ STNDRDZD FORM,3296125,CDM,440,RC,96125,HCPCS,Outpatient,,,406.25,243.75,,345.31,85,,276.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.12,80.03,,260.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,100.14,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,365.63,90,,292.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.14,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,130.61,32.15,,104.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.5,88,,286,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.51,33.11,,107.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.61,365.63,
CPAP,30300,CDM,410,RC,94660,HCPCS,Outpatient,,,406.52,243.91,,345.54,85,,276.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.7,32.15,,104.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.34,80.03,,260.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,365.87,90,,292.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.7,32.15,,104.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,130.7,32.15,,104.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.74,88,,286.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.6,33.11,,107.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.7,365.87,
"QUADSCREEN, AFP  (MAYO)",1886240,CDM,300,RC,81511,HCPCS,Outpatient,,,406.75,244.05,,345.74,85,,276.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,325.52,80.03,,260.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,156.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,366.08,90,,292.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,156.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,122.8,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,357.94,88,,286.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,122.8,366.08,
LEVEL 1 AIRWAY ENDOSCOPY,9110,CDM,790,RC,,,Outpatient,,,406.75,244.05,,345.74,85,,276.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.77,32.15,,104.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.52,80.03,,260.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,366.08,90,,292.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.77,32.15,,104.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.77,32.15,,104.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.94,88,,286.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.67,33.11,,107.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.77,366.08,
Ultrasound of the scrotum,24020,CDM,402,RC,76870,HCPCS,Outpatient,,,407.5,244.5,,346.38,85,,277.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.01,32.15,,104.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.12,80.03,,260.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,366.75,90,,293.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.01,32.15,,104.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,131.01,32.15,,104.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,358.6,88,,286.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.92,33.11,,107.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.01,366.75,
INSERTION OF FOLEY CATH,51702,CDM,761,RC,51702,HCPCS,Outpatient,,,407.5,244.5,,346.38,85,,277.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.01,32.15,,104.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.12,80.03,,260.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,366.75,90,,293.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.01,32.15,,104.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,131.01,32.15,,104.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,358.6,88,,286.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.92,33.11,,107.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.01,366.75,
DIFLUCAN  (fluconazole) 400MG /200ML PB,293349,CDM,636,RC,J1450,HCPCS,Outpatient,,,408,244.8,,346.8,85,,277.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,326.52,80.03,,261.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.2,90,,293.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,359.04,88,,287.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.31,367.2,
SLEEP APNEA STUDY,49092,CDM,270,RC,,,Outpatient,,,408.5,245.1,,347.23,85,,277.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.92,80.03,,261.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.65,90,,294.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.48,88,,287.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.25,33.11,,108.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.33,367.65,
CONSCIOUS SEDATION 1ST 15 MIN.,11040,CDM,372,RC,99151,HCPCS,Outpatient,,,408.5,245.1,,347.23,85,,277.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.92,80.03,,261.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.65,90,,294.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.48,88,,287.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.25,33.11,,108.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.33,367.65,
CONSCIOUS SEDATION ADDL 15 MIN OVER 5 YR,11046,CDM,372,RC,99153,HCPCS,Outpatient,,,408.5,245.1,,347.23,85,,277.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.92,80.03,,261.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.65,90,,294.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.48,88,,287.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.25,33.11,,108.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.33,367.65,
MOD SEDATION SAME MD/QHP INITIAL 15 MIN.,99152,CDM,450,RC,99152,HCPCS,Outpatient,,,408.5,245.1,,347.23,85,,277.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.92,80.03,,261.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.65,90,,294.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.33,32.15,,105.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.48,88,,287.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.25,33.11,,108.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.33,367.65,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",22341,CDM,403,RC,77066,HCPCS,Outpatient,,,408.75,245.25,,347.44,85,,277.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.41,32.15,,105.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,327.12,80.03,,261.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,101.75,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,367.88,90,,294.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.41,32.15,,105.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.75,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,131.41,32.15,,105.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.7,88,,287.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.34,33.11,,108.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.41,367.88,
"New patient office of other outpatient visit, typically 45 min",99204,CDM,510,RC,99204,HCPCS,Outpatient,,,408.75,245.25,,347.44,85,,277.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.41,32.15,,105.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,327.12,80.03,,261.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.88,90,,294.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.41,32.15,,105.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.41,32.15,,105.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.7,88,,287.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.34,33.11,,108.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.41,367.88,
TOMOGRAPHY,22125,CDM,320,RC,76100,HCPCS,Outpatient,,,409,245.4,,347.65,85,,278.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.49,32.15,,105.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,327.32,80.03,,261.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,368.1,90,,294.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.49,32.15,,105.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,131.49,32.15,,105.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.92,88,,287.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.42,33.11,,108.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.49,368.1,
Serial radiologic examination of the abdomen,22205,CDM,320,RC,74022,HCPCS,Outpatient,,,409,245.4,,347.65,85,,278.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.49,32.15,,105.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,327.32,80.03,,261.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,368.1,90,,294.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.49,32.15,,105.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,131.49,32.15,,105.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.92,88,,287.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.42,33.11,,108.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.49,368.1,
SEROTONIN RELEASE ASSAY  (MAYO),1886023,CDM,300,RC,86022,HCPCS,Outpatient,,,409.75,245.85,,348.29,85,,278.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,327.92,80.03,,262.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.73,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,368.78,90,,295.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.73,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,23.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,360.58,88,,288.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.09,368.78,
SURFIT LOOP OSTOMY SYSTEM 2 3/4,493214,CDM,270,RC,,,Outpatient,,,410,246,,348.5,85,,278.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.82,32.15,,105.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,328.12,80.03,,262.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369,90,,295.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.82,32.15,,105.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.82,32.15,,105.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,360.8,88,,288.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.75,33.11,,108.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.82,369,
"Established patient office or other outpatient, visit typically 40 minutes",99215,CDM,510,RC,99215,HCPCS,Outpatient,,,411,246.6,,349.35,85,,279.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,132.14,32.15,,105.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,328.92,80.03,,263.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369.9,90,,295.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,132.14,32.15,,105.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,132.14,32.15,,105.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.68,88,,289.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,136.08,33.11,,108.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,132.14,369.9,
US OB MULT GEST,24098,CDM,402,RC,76810,HCPCS,Outpatient,,,411.75,247.05,,349.99,85,,279.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,132.38,32.15,,105.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,329.52,80.03,,263.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.58,90,,296.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,132.38,32.15,,105.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,132.38,32.15,,105.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,362.34,88,,289.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,136.33,33.11,,109.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,132.38,370.58,
DIAMOX (acetazolamide) :500MG INJ,293067,CDM,636,RC,J1120,HCPCS,Outpatient,,,412,247.2,,350.2,85,,280.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,26.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,329.72,80.03,,263.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.8,90,,296.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,26.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,26.32,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,362.56,88,,290.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,26.32,370.8,
"FLUORO,FINE NEEDLE ASPIRATION,EA ADD LES",10008,CDM,320,RC,10008,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
T-BLOCK (OR),13020,CDM,370,RC,,,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
EPIDURAL - OR,13030,CDM,370,RC,,,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CAUDEL-MTR&SUP (OR),13035,CDM,370,RC,,,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
US FINE NEEDLE ASPIRATION EA ADD LESION,10006,CDM,402,RC,10006,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX NASAL FX W/O MANIP,1421310,CDM,450,RC,21310,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TEMPOROMANIDIBULAR DISLOC,1421480,CDM,450,RC,21480,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLOSED TX STERNUM FX,1421820,CDM,450,RC,21820,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
UNLISTED PROCEDURE SPINE,1422899,CDM,450,RC,22899,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX CLAVICLE FX W/O MANIP,1423500,CDM,450,RC,23500,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX CLAVICLE DISLOC W/MANIP,1423525,CDM,450,RC,23525,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX AC JOINT DISLOCATION W/O MAN,1423540,CDM,450,RC,23540,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX AC DISLOCATION W/MAN,1423545,CDM,450,RC,23545,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLOSED SCAPULAR FRACTURE W/O MAN,1423570,CDM,450,RC,23570,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX PROXIMAL HUMERAL FX W/O MANIP,1423600,CDM,450,RC,23600,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX PROXIMAL HUMERAL TUBEROSITY FX W,1423620,CDM,450,RC,23620,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
UNLISTED PROCEDURE SHOULDER,1423929,CDM,450,RC,23929,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TREAT HUMERAL FX W/O MAN,1424500,CDM,450,RC,24500,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DISTAL HUMERAL FX W/O MANIP,1424530,CDM,450,RC,24530,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TX HUMERAL EPICONDYLAR FX W/O MANIP,1424560,CDM,450,RC,24560,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TX HUMERAL CONDYLAR FX W/O MANIP,1424576,CDM,450,RC,24576,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX RADIAL HEADFX W/O MAN,1424650,CDM,450,RC,24650,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX ULNA FX PROXIMAL W/O MANIP,1424670,CDM,450,RC,24670,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
UNLISTED PROCEDURE HUMERUS OR ELBOW,1424999,CDM,450,RC,24999,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX RADIAL SHAFT FX W/O MANI,1425500,CDM,450,RC,25500,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX ULNAR SHAFT FX W/O MANIP,1425530,CDM,450,RC,25530,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX ULNAR SHAFT FX W/MANIP,1425535,CDM,450,RC,25535,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX RADIUS & ULNA W/O MANIP,1425560,CDM,450,RC,25560,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DISTAL RADIAL FX W/O MAN,1425600,CDM,450,RC,25600,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX NAVICULAR FX W/O MANIP,1425622,CDM,450,RC,25622,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX FX CARPAL BONE  W/O MANIP EA,1425630,CDM,450,RC,25630,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX ULNAR STYLOID FX,1425650,CDM,450,RC,25650,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX RADIOCARP DISL ONE OR MORE W/MAN,1425660,CDM,450,RC,25660,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DISTAL RADIOULNAR DISLOC W/MANIP,1425675,CDM,450,RC,25675,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
UNLISTED PROCEDURE FOREARM OR WRIST,1425999,CDM,450,RC,25999,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX METACARPAL FX W/O MANIP EACH,1426600,CDM,450,RC,26600,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX METACARPAL FX W/MANIP EACH,1426605,CDM,450,RC,26605,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX CARPO-M DISLOC THUMB W/MANIP,1426641,CDM,450,RC,26641,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX CARPO-MC DISLOC (NOT THUMB) W/MA,1426670,CDM,450,RC,26670,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX MCP DISLOCATION W/MANIP W/O ANES,1426700,CDM,450,RC,26700,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"CLSD TX FINGER FRACTURE W/O MANIP, EACH",1426720,CDM,450,RC,26720,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"CLSD TX FINGER FRACTURE W/ MANIP, EACH",1426725,CDM,450,RC,26725,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX ARTICULAR FX W/O MAN,1426740,CDM,450,RC,26740,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DISTAL TUFT FX W/O MANIP,1426750,CDM,450,RC,26750,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DISTAL TUFT FX W/ MANIP,1426755,CDM,450,RC,26755,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"UNLISTED PROCEDURE, HANDS OR FINGERS",1426989,CDM,450,RC,26989,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLOSED TX PELVIC RING FRACTURE W/O MANIP,1427193,CDM,450,RC,27197,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TX COCCYGEAL FX,1427200,CDM,450,RC,27200,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLOSED TX HIP SOCKET FRACTURE W/O MANIP,1427220,CDM,450,RC,27220,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX FEMORAL FX PROXIMAL END W/O MANI,1427230,CDM,450,RC,27230,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TX GREATER TROCHANTERIC FX,1427246,CDM,450,RC,27246,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TX HIP DISLOCATION BY ABDUCTION W/O ANES,1427256,CDM,450,RC,27256,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX POST HIP DISLOC,1427265,CDM,450,RC,27265,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"UNLISTED PROCEDURE, PELVIS OR HIP",1427299,CDM,450,RC,27299,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX FEMORAL SHAFT FX W/O MANIP,1427500,CDM,450,RC,27500,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX SUPRA OR TRANSCONDYLAR FEMURAL F,1427501,CDM,450,RC,27501,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX FEMORAL FX DISTAL END W/O MANIP,1427508,CDM,450,RC,27508,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DISTAL FEMORAL EPIPHYSEAL SEPERA,1427516,CDM,450,RC,27516,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX PATELLAR FX W/O MAN,1427520,CDM,450,RC,27520,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TX TIBAL PLATEAU FX W/O MANIP,1427530,CDM,450,RC,27530,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX OF KNEE FRACTURE,1427538,CDM,450,RC,27538,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX KNEE DISLOC,1427550,CDM,450,RC,27550,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"UNLISTED PROCEDURE, FEMUR OR KNEE",1427599,CDM,450,RC,27599,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TIB FX W/O MAN,1427750,CDM,450,RC,27750,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX FX MED. MALLEOLUS W/O MANIP,1427760,CDM,450,RC,27760,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX PROXIMAL FIBULA FX W/O MAN,1427780,CDM,450,RC,27780,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DIS FIBULA W/O MANIP,1427786,CDM,450,RC,27786,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX DIS FIBULA W/ MANIP,1427788,CDM,450,RC,27788,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX BIMALLEOLAR ANKLE FX W/O MANIP,1427808,CDM,450,RC,27808,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TREATMENT OF ANKLE FRACTURE,1427816,CDM,450,RC,27816,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TREAT LOWER LEG FRACTURE,1427824,CDM,450,RC,27824,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
TREAT LOWER LEG DISLOCATION,1427830,CDM,450,RC,27830,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"UNLISTED PROCEDURE, LEG OR ANKLE",1427899,CDM,450,RC,27899,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX CALCANEAL FX W/O MAN,1428400,CDM,450,RC,28400,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX CALCANEAL FX W/ MANIP,1428405,CDM,450,RC,28405,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TALUS FX W/O MANIP,1428430,CDM,450,RC,28430,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"TX TARSAL BONE FX W/O MAN, EACH",1428450,CDM,450,RC,28450,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX METATARSAL FX W/O MANIP EACH,1428470,CDM,450,RC,28470,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX METATARSAL FX W/MANIP EAC,1428475,CDM,450,RC,28475,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX BIG TOE FX W/O MANIP,1428490,CDM,450,RC,28490,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX BIG TOE FX W/ MANIP,1428495,CDM,450,RC,28495,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TOE FX W/O MANIP,1428510,CDM,450,RC,28510,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TOE FX W/ MANIP,1428515,CDM,450,RC,28515,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX SESAMOID FRACTURE,1428530,CDM,450,RC,28530,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TARSAL BONE DISL,1428540,CDM,450,RC,28540,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX TARSAL JT DISLOC,1428570,CDM,450,RC,28570,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX T-MT JOINT DISL,1428600,CDM,450,RC,28600,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX METATARSCOPHA JT DISLOC,1428630,CDM,450,RC,28630,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CLSD TX CLOSED IPJ DICLOC,1428660,CDM,450,RC,28660,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
"UNLISTED PROCEDURE, FOOT OR TOES",1428899,CDM,450,RC,28899,HCPCS,Outpatient,,,414,248.4,,351.9,85,,281.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.32,80.03,,265.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,372.6,90,,298.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,133.1,32.15,,106.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.32,88,,291.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.08,33.11,,109.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.1,372.6,
CT BONE DENSITY SPINE,26088,CDM,320,RC,77078,HCPCS,Outpatient,,,415.75,249.45,,353.39,85,,282.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.66,32.15,,106.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.72,80.03,,266.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,374.18,90,,299.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.66,32.15,,106.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,133.66,32.15,,106.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.86,88,,292.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.65,33.11,,110.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.66,374.18,
MATTRESS PULMONEX,49094,CDM,270,RC,,,Outpatient,,,416,249.6,,353.6,85,,282.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.92,80.03,,266.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.4,90,,299.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,416,,,,Other,Not Separately reimbursable,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.08,88,,292.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.74,33.11,,110.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.74,374.4,
O/T ELBOW GUTTER SPLINT,3947,CDM,274,RC,L3986,HCPCS,Outpatient,,,416,249.6,,353.6,85,,282.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.92,80.03,,266.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.4,90,,299.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,416,,,,Other,Not Separately reimbursable,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.08,88,,292.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.74,33.11,,110.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.74,374.4,
I & D BARTHOLIN ABSCESS,1456420,CDM,450,RC,56420,HCPCS,Outpatient,,,416,249.6,,353.6,85,,282.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.92,80.03,,266.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,170.77,102,,,fee schedule,Pays at 102% of CMS APC rate,374.4,90,,299.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.77,100,,,fee schedule,Pays at 100% of CMS APC rate,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.08,88,,292.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.74,33.11,,110.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.74,374.4,
LEVEL 2 GYNECOLOGIC PROCEDURES,9120,CDM,790,RC,,,Outpatient,,,416,249.6,,353.6,85,,282.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.92,80.03,,266.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.4,90,,299.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,416,,,,Other,Not Separately reimbursable,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.08,88,,292.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.74,33.11,,110.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.74,374.4,
A common prenatal test used to check on a baby's health.,6017,CDM,920,RC,59025,HCPCS,Outpatient,,,416,249.6,,353.6,85,,282.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.92,80.03,,266.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,170.77,102,,,fee schedule,Pays at 102% of CMS APC rate,374.4,90,,299.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.77,100,,,fee schedule,Pays at 100% of CMS APC rate,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.08,88,,292.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.74,33.11,,110.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.74,374.4,
OPEN BED (DAILY),8080,CDM,270,RC,,,Outpatient,,,418,250.8,,355.3,85,,284.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,334.53,80.03,,267.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.2,90,,300.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,418,,,,Other,Not Separately reimbursable,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,367.84,88,,294.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.4,33.11,,110.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.39,376.2,
US BREAST WITH ASPIRATION,24029,CDM,402,RC,76942,HCPCS,Outpatient,,,418,250.8,,355.3,85,,284.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,334.53,80.03,,267.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.2,90,,300.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,418,,,,Other,Not Separately reimbursable,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,367.84,88,,294.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.4,33.11,,110.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.39,376.2,
US FOR CYST,24089,CDM,402,RC,76999,HCPCS,Outpatient,,,418,250.8,,355.3,85,,284.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,334.53,80.03,,267.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,376.2,90,,300.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,367.84,88,,294.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.4,33.11,,110.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.39,376.2,
FETAL MONITORING INTERNAL,6010,CDM,721,RC,,,Outpatient,,,418,250.8,,355.3,85,,284.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,334.53,80.03,,267.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.2,90,,300.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,418,,,,Other,Not Separately reimbursable,134.39,32.15,,107.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,367.84,88,,294.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.4,33.11,,110.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.39,376.2,
MPL MUTATION EXON 10  (CSI),2188392,CDM,300,RC,81402,HCPCS,Outpatient,,,418.6,251.16,,355.81,85,,284.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,164,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,335.01,80.03,,268.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,153.33,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,376.74,90,,301.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,164,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,153.33,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,164,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,368.37,88,,294.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,168.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,164,376.74,
AMPLIFIED M.TUBERCULOSIS  (MAYO),1887556,CDM,300,RC,87556,HCPCS,Outpatient,,,419.25,251.55,,356.36,85,,285.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.79,32.15,,107.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,335.53,80.03,,268.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,42.51,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,377.33,90,,301.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.79,32.15,,107.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.51,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,134.79,32.15,,107.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,368.94,88,,295.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.81,33.11,,111.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.79,377.33,
LASER SHIELD 7.0MM X 10.5MM 31 FR,49902,CDM,270,RC,,,Outpatient,,,420,252,,357,85,,285.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.03,32.15,,108.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,336.13,80.03,,268.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378,90,,302.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.03,32.15,,108.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.03,32.15,,108.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.6,88,,295.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.06,33.11,,111.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.03,378,
PROLONGED DETETION UP TO 1 HR,1499150,CDM,450,RC,,,Outpatient,,,420.25,252.15,,357.21,85,,285.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,336.33,80.03,,269.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.23,90,,302.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.82,88,,295.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.14,33.11,,111.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.11,378.23,
APPLICATION OF BILATERAL MULTI LAYER,2958150,CDM,761,RC,29581,HCPCS,Outpatient,,,420.25,252.15,,357.21,85,,285.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,336.33,80.03,,269.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,378.23,90,,302.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.82,88,,295.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.14,33.11,,111.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.11,378.23,
"HERPES, PCR, CSF  (MAYO)",1883899,CDM,300,RC,83898,HCPCS,Outpatient,,,420.5,252.3,,357.43,85,,285.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.19,32.15,,108.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,336.53,80.03,,269.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.45,90,,302.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.19,32.15,,108.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.19,32.15,,108.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,370.04,88,,296.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.23,33.11,,111.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.19,378.45,
ALS NONEMERGENCY TRANSPORT NO SPEC ALS,530324,CDM,540,RC,A0426,HCPCS,Outpatient,,,420.55,252.33,,357.47,85,,285.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.21,32.15,,108.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,336.57,80.03,,269.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.5,90,,302.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.21,32.15,,108.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.21,32.15,,108.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,370.08,88,,296.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.24,33.11,,111.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.21,378.5,
TRAY LUMBAR PUNCTURE INFANT,492092,CDM,270,RC,,,Outpatient,,,421.25,252.75,,358.06,85,,286.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.43,32.15,,108.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.13,80.03,,269.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,379.13,90,,303.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.43,32.15,,108.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.43,32.15,,108.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,370.7,88,,296.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.48,33.11,,111.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.43,379.13,
US COLOR FLOW ECHO,24125,CDM,480,RC,93325,HCPCS,Outpatient,,,421.5,252.9,,358.28,85,,286.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.51,32.15,,108.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.33,80.03,,269.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,379.35,90,,303.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.51,32.15,,108.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.51,32.15,,108.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,370.92,88,,296.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.56,33.11,,111.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.51,379.35,
HEARING/SCREENING,6012,CDM,479,RC,92586,HCPCS,Outpatient,,,424.25,254.55,,360.61,85,,288.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,136.4,32.15,,109.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,339.53,80.03,,271.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,381.83,90,,305.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,136.4,32.15,,109.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,136.4,32.15,,109.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.34,88,,298.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,140.47,33.11,,112.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,136.4,381.83,
ZOVIRAX (acyclovir) 5% OINT 15G,298038,CDM,250,RC,,,Outpatient,,,425,255,,361.25,85,,289,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,136.64,32.15,,109.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,340.13,80.03,,272.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,382.5,90,,306,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,136.64,32.15,,109.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,136.64,32.15,,109.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,374,88,,299.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,140.72,33.11,,112.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,136.64,382.5,
COVID 4 PLEX PCR,1886715,CDM,300,RC,0241U,HCPCS,Outpatient,,,425,255,,361.25,85,,289,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,340.13,80.03,,272.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,145.48,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,382.5,90,,306,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,145.48,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,142.63,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,374,88,,299.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,142.63,382.5,
ADVAIR 500/50 DISKUS  # 60 PAKS,292125,CDM,636,RC,J3535,HCPCS,Outpatient,,,425,255,,361.25,85,,289,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,136.64,32.15,,109.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,340.13,80.03,,272.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,382.5,90,,306,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,136.64,32.15,,109.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,136.64,32.15,,109.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,374,88,,299.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,140.72,33.11,,112.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,136.64,382.5,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24007,CDM,402,RC,76705,HCPCS,Outpatient,,,427.5,256.5,,363.38,85,,290.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,137.44,32.15,,109.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,342.13,80.03,,273.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,384.75,90,,307.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,137.44,32.15,,109.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,137.44,32.15,,109.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.2,88,,300.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,141.55,33.11,,113.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,137.44,384.75,
DRESSING LARGE ULTA VERAFLO CLEANSE,49690,CDM,270,RC,,,Outpatient,,,429.2,257.52,,364.82,85,,291.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,137.99,32.15,,110.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,343.49,80.03,,274.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,386.28,90,,309.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,137.99,32.15,,110.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,137.99,32.15,,110.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,377.7,88,,302.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,142.11,33.11,,113.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,137.99,386.28,
COAG FACTOR VIII INHIB SC (MAYO),1885313,CDM,300,RC,85335,HCPCS,Outpatient,,,429.5,257.7,,365.08,85,,292.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,343.73,80.03,,274.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,13.12,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,386.55,90,,309.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.12,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,377.96,88,,302.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.68,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.19,386.55,
Draining or injecting medication into a major joint/bursa without ultrasound,22315,CDM,320,RC,20610,HCPCS,Outpatient,,,431.25,258.75,,366.56,85,,293.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,138.65,32.15,,110.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,345.13,80.03,,276.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,388.13,90,,310.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,138.65,32.15,,110.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,138.65,32.15,,110.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,379.5,88,,303.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,142.79,33.11,,114.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,138.65,388.13,
THORACENTESIS CHEST,22369,CDM,320,RC,32555,HCPCS,Outpatient,,,432.75,259.65,,367.84,85,,294.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,139.13,32.15,,111.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,346.33,80.03,,277.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,389.48,90,,311.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,139.13,32.15,,111.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,139.13,32.15,,111.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,380.82,88,,304.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,143.28,33.11,,114.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,139.13,389.48,
CLONIDINE  (MAYO),1882513,CDM,300,RC,82542,HCPCS,Outpatient,,,433.5,260.1,,368.48,85,,294.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,346.93,80.03,,277.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,390.15,90,,312.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,381.48,88,,305.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,390.15,
COMPLETE BILATERAL PHYSIOLOGIC STUDY,93923,CDM,921,RC,93923,HCPCS,Outpatient,,,433.5,260.1,,368.48,85,,294.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,139.37,32.15,,111.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,346.93,80.03,,277.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,390.15,90,,312.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,139.37,32.15,,111.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,139.37,32.15,,111.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,381.48,88,,305.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,143.53,33.11,,114.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,139.37,390.15,
STENT 6FR X 24 CONTOUR INJECTION,496368,CDM,270,RC,,,Outpatient,,,433.75,260.25,,368.69,85,,294.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,139.45,32.15,,111.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,347.13,80.03,,277.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390.38,90,,312.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,139.45,32.15,,111.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,139.45,32.15,,111.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,381.7,88,,305.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,143.61,33.11,,114.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,139.45,390.38,
STENT 7FR X 24 CONTOUR INJECTION,496369,CDM,270,RC,,,Outpatient,,,433.75,260.25,,368.69,85,,294.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,139.45,32.15,,111.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,347.13,80.03,,277.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390.38,90,,312.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,139.45,32.15,,111.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,139.45,32.15,,111.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,381.7,88,,305.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,143.61,33.11,,114.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,139.45,390.38,
SURGICEL 4 X 8,493340,CDM,270,RC,,,Outpatient,,,435,261,,369.75,85,,295.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,139.85,32.15,,111.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,348.13,80.03,,278.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.5,90,,313.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,139.85,32.15,,111.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,139.85,32.15,,111.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,382.8,88,,306.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.03,33.11,,115.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,139.85,391.5,
IVP NEPHROTOMOGRAPHY,22322,CDM,320,RC,74415,HCPCS,Outpatient,,,435.25,261.15,,369.96,85,,295.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,139.93,32.15,,111.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,348.33,80.03,,278.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,391.73,90,,313.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,139.93,32.15,,111.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,139.93,32.15,,111.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,383.02,88,,306.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.11,33.11,,115.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,139.93,391.73,
O/T WHFO-EXTENSION SPLINT W/OUTRIGGER FI,3982,CDM,274,RC,L3916,HCPCS,Outpatient,,,436.5,261.9,,371.03,85,,296.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.33,32.15,,112.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.33,80.03,,279.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.85,90,,314.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.33,32.15,,112.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,140.33,32.15,,112.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.12,88,,307.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.53,33.11,,115.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.33,392.85,
Separation and removal of the entire nail plate or a portion of nail plate,1411730,CDM,450,RC,11730,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
SIM LAC 7.6-12.5 CM,1412004,CDM,450,RC,12004,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
SIM LAC 2.6-5.0 CM,1412013,CDM,450,RC,12013,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
SIM LAC 7.6-12.5 CM,1412015,CDM,450,RC,12015,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
Incision and drainage of abscess; simple or single and complex or multiple,10060,CDM,761,RC,10060,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
PARING OR CUTTING BENIGN HYPERKERATOTIC,11055,CDM,761,RC,11055,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
Separation and removal of the entire nail plate or a portion of nail plate,11730,CDM,761,RC,11730,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
Chemical destruction of pre-cancerous lesions of the skin,17250,CDM,761,RC,17250,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
DRESS AND/OR DEBRIDE PARTIAL BURN SMALL,8416020,CDM,761,RC,16020,HCPCS,Outpatient,,,436.75,262.05,,371.24,85,,296.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.53,80.03,,279.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,393.08,90,,314.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,140.42,32.15,,112.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,88,,307.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.61,33.11,,115.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.42,393.08,
ADVAIR 100/50  DISKUS  *HOSP* #14,292123,CDM,636,RC,J3535,HCPCS,Outpatient,,,436.99,262.19,,371.44,85,,297.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.49,32.15,,112.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.72,80.03,,279.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.29,90,,314.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.49,32.15,,112.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,140.49,32.15,,112.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.55,88,,307.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.69,33.11,,115.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.49,393.29,
ADVAIR 250/50 DISKUS  *HOSP* #14,292126,CDM,636,RC,J3535,HCPCS,Outpatient,,,436.99,262.19,,371.44,85,,297.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.49,32.15,,112.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,349.72,80.03,,279.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.29,90,,314.63,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.49,32.15,,112.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,140.49,32.15,,112.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.55,88,,307.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.69,33.11,,115.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.49,393.29,
TRAY CRICOTHYROTOMY PEDIATRICS,492316,CDM,270,RC,,,Outpatient,,,437.75,262.65,,372.09,85,,297.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.74,32.15,,112.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.33,80.03,,280.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.98,90,,315.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.74,32.15,,112.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,140.74,32.15,,112.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.22,88,,308.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,144.94,33.11,,115.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.74,393.98,
APPLY SHORT LEG SPLINT (CALF TO FOOT),1429515,CDM,450,RC,29515,HCPCS,Outpatient,,,438.44,263.06,,372.67,85,,298.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.96,32.15,,112.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.88,80.03,,280.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,394.6,90,,315.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.96,32.15,,112.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,140.96,32.15,,112.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.83,88,,308.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.17,33.11,,116.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.96,394.6,
APPLY MULTILAYER COMP LOWER LEG,8429581,CDM,761,RC,29581,HCPCS,Outpatient,,,438.44,263.06,,372.67,85,,298.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.96,32.15,,112.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.88,80.03,,280.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,394.6,90,,315.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.96,32.15,,112.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,140.96,32.15,,112.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.83,88,,308.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.17,33.11,,116.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.96,394.6,
NM IODINE 123,2932287,CDM,343,RC,A9516,HCPCS,Outpatient,,,438.53,263.12,,372.75,85,,298.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,140.99,32.15,,112.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.96,80.03,,280.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.68,90,,315.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,140.99,32.15,,112.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,140.99,32.15,,112.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.91,88,,308.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.2,33.11,,116.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,140.99,394.68,
"MYOTONIC DYSTROPHY, MOLECULAR ANALYSIS",1883889,CDM,300,RC,83896,HCPCS,Outpatient,,,438.75,263.25,,372.94,85,,298.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.06,32.15,,112.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,351.13,80.03,,280.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.88,90,,315.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.06,32.15,,112.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,141.06,32.15,,112.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,386.1,88,,308.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.27,33.11,,116.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.06,394.88,
ELECTRODE MULTI-FUNCTION PEDI ZOLL CONN,49077,CDM,270,RC,,,Outpatient,,,440,264,,374,85,,299.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.13,80.03,,281.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396,90,,316.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.2,88,,309.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.68,33.11,,116.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.46,396,
ELECTRODE QUIK-COMBO PEDIATRIC PHYSIO,49087,CDM,270,RC,,,Outpatient,,,440,264,,374,85,,299.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.13,80.03,,281.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396,90,,316.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.2,88,,309.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.68,33.11,,116.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.46,396,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",97597,CDM,761,RC,97597,HCPCS,Outpatient,,,440.63,264.38,,374.54,85,,299.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.66,32.15,,113.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.64,80.03,,282.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,396.57,90,,317.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.66,32.15,,113.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,141.66,32.15,,113.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.75,88,,310.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.89,33.11,,116.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.66,396.57,
CATHFLO (activase) 2mg,293820,CDM,636,RC,J2997,HCPCS,Outpatient,,,440.81,264.49,,374.69,85,,299.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.72,32.15,,113.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.78,80.03,,282.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,90.94,102,,,fee schedule,Pays at 102% of CMS APC rate,396.73,90,,317.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.72,32.15,,113.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.94,100,,,fee schedule,Pays at 100% of CMS APC rate,141.72,32.15,,113.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.91,88,,310.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.95,33.11,,116.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.72,396.73,
TM JOINTS BILAT,22016,CDM,320,RC,70330,HCPCS,Outpatient,,,442,265.2,,375.7,85,,300.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.73,80.03,,282.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,397.8,90,,318.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.96,88,,311.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.35,33.11,,117.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.1,397.8,
CT LUNG SCREENING WO CONTRAST,26115,CDM,352,RC,71271,HCPCS,Outpatient,,,442,265.2,,375.7,85,,300.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.73,80.03,,282.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,397.8,90,,318.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.96,88,,311.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.35,33.11,,117.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.1,397.8,
Ultrasound of back wall of the abdomen with limited areas viewed,24012,CDM,402,RC,76775,HCPCS,Outpatient,,,443.75,266.25,,377.19,85,,301.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,355.13,80.03,,284.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,399.38,90,,319.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.5,88,,312.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.93,33.11,,117.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.67,399.38,
US BREAST UNILATERAL LT,24090,CDM,402,RC,76641,HCPCS,Outpatient,,,443.75,266.25,,377.19,85,,301.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,355.13,80.03,,284.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,399.38,90,,319.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.5,88,,312.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.93,33.11,,117.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.67,399.38,
US BREAST UNILATERAL RT,24113,CDM,402,RC,76641,HCPCS,Outpatient,,,443.75,266.25,,377.19,85,,301.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,355.13,80.03,,284.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,399.38,90,,319.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,142.67,32.15,,114.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.5,88,,312.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.93,33.11,,117.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.67,399.38,
Draining or injecting medication into a major joint/bursa without ultrasound,22339,CDM,320,RC,20610,HCPCS,Outpatient,,,444.25,266.55,,377.61,85,,302.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.83,32.15,,114.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,355.53,80.03,,284.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,399.83,90,,319.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.83,32.15,,114.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,142.83,32.15,,114.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.94,88,,312.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,147.09,33.11,,117.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.83,399.83,
"STREPTOKINASE: 750,000U INJ",293175,CDM,636,RC,J2995,HCPCS,Outpatient,,,445.74,267.44,,378.88,85,,303.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,143.31,32.15,,114.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,356.73,80.03,,285.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,401.17,90,,320.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,143.31,32.15,,114.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.31,32.15,,114.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,392.25,88,,313.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,147.58,33.11,,118.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,143.31,401.17,
IRRIGATION OF BLADDER,1451700,CDM,450,RC,51700,HCPCS,Outpatient,,,447,268.2,,379.95,85,,303.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,143.71,32.15,,114.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.73,80.03,,286.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,205.98,102,,,fee schedule,Pays at 102% of CMS APC rate,402.3,90,,321.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,143.71,32.15,,114.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.98,100,,,fee schedule,Pays at 100% of CMS APC rate,143.71,32.15,,114.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,393.36,88,,314.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,148,33.11,,118.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,143.71,402.3,
P/T EVAL DO NOT USE AFTER 12/2016,315,CDM,424,RC,97001,HCPCS,Outpatient,,,447.25,268.35,,380.16,85,,304.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.93,80.03,,286.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402.53,90,,322.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,393.58,88,,314.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,148.08,33.11,,118.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,143.79,402.53,
O/T EVAL DO NOT USE AFTER 12/2016,3151,CDM,434,RC,97003,HCPCS,Outpatient,,,447.25,268.35,,380.16,85,,304.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.93,80.03,,286.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402.53,90,,322.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,393.58,88,,314.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,148.08,33.11,,118.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,143.79,402.53,
Therapy for speech or hearing,322014,CDM,440,RC,92507,HCPCS,Outpatient,,,447.25,268.35,,380.16,85,,304.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.93,80.03,,286.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.96,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,402.53,90,,322.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.96,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,143.79,32.15,,115.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,393.58,88,,314.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,148.08,33.11,,118.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,143.79,402.53,
PORT US EXTREMITY NON-VASCUL,24055,CDM,402,RC,76881,HCPCS,Outpatient,,,448.5,269.1,,381.23,85,,304.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,144.19,32.15,,115.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,358.93,80.03,,287.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,403.65,90,,322.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,144.19,32.15,,115.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,144.19,32.15,,115.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,394.68,88,,315.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,148.5,33.11,,118.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,144.19,403.65,
IV BAM+ETESEVIMAB  ADMINISTRATION,290087,CDM,771,RC,M0245,HCPCS,Outpatient,,,450,270,,382.5,85,,306,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,360.14,80.03,,288.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,431.89,102,,,fee schedule,Pays at 102% of CMS APC rate,405,90,,324,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,431.89,100,,,fee schedule,Pays at 100% of CMS APC rate,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,396,88,,316.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,149,33.11,,119.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,144.68,405,
IV REGEN-COV ADMINISTRATION & MONITORING,290088,CDM,771,RC,M0243,HCPCS,Outpatient,,,450,270,,382.5,85,,306,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,360.14,80.03,,288.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,431.89,102,,,fee schedule,Pays at 102% of CMS APC rate,405,90,,324,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,431.89,100,,,fee schedule,Pays at 100% of CMS APC rate,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,396,88,,316.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,149,33.11,,119.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,144.68,405,
IV SOTROVIMAB ADMINISTRATION & MONITOR,290089,CDM,771,RC,M0247,HCPCS,Outpatient,,,450,270,,382.5,85,,306,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,360.14,80.03,,288.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,431.89,102,,,fee schedule,Pays at 102% of CMS APC rate,405,90,,324,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,431.89,100,,,fee schedule,Pays at 100% of CMS APC rate,144.68,32.15,,115.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,396,88,,316.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,149,33.11,,119.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,144.68,405,
RABIES (IMOVAX) VACCINE 1ML,293208,CDM,636,RC,90675,HCPCS,Outpatient,,,453,271.8,,385.05,85,,308.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,328.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,362.54,80.03,,290.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,335.12,102,,,fee schedule,Pays at 102% of CMS APC rate,407.7,90,,326.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,328.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,335.12,100,,,fee schedule,Pays at 100% of CMS APC rate,328.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,398.64,88,,318.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,338.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,328.55,407.7,
DISPOSABLE PACING CABLE,4999935,CDM,278,RC,C1883,HCPCS,Outpatient,,,453.5,272.1,,385.48,85,,308.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,145.8,32.15,,116.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,362.94,80.03,,290.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.15,90,,326.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,145.8,32.15,,116.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,145.8,32.15,,116.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,399.08,88,,319.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,150.15,33.11,,120.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,145.8,408.15,
APPLY TOTAL CONTACT LEG CAST,8429445,CDM,761,RC,29445,HCPCS,Outpatient,,,454.5,272.7,,386.33,85,,309.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.12,32.15,,116.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,363.74,80.03,,290.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,409.05,90,,327.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.12,32.15,,116.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,146.12,32.15,,116.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,399.96,88,,319.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,150.48,33.11,,120.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.12,409.05,
APPLY UNNA BOOT,8429580,CDM,761,RC,29580,HCPCS,Outpatient,,,454.5,272.7,,386.33,85,,309.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.12,32.15,,116.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,363.74,80.03,,290.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,409.05,90,,327.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.12,32.15,,116.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,146.12,32.15,,116.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,399.96,88,,319.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,150.48,33.11,,120.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.12,409.05,
TRAY SPINAL ANESTHESIA 25G X 3.5,492093,CDM,270,RC,,,Outpatient,,,455,273,,386.75,85,,309.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.28,32.15,,117.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.14,80.03,,291.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.5,90,,327.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.28,32.15,,117.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,146.28,32.15,,117.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,400.4,88,,320.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,150.65,33.11,,120.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.28,409.5,
KIT BIOPREP BONE PREPARATION,499987,CDM,270,RC,,,Outpatient,,,455.5,273.3,,387.18,85,,309.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.44,32.15,,117.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.54,80.03,,291.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.95,90,,327.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.44,32.15,,117.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,146.44,32.15,,117.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,400.84,88,,320.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,150.82,33.11,,120.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.44,409.95,
TOGA FLYTE 2XL PEEL AWAY,499992,CDM,270,RC,,,Outpatient,,,455.5,273.3,,387.18,85,,309.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.44,32.15,,117.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.54,80.03,,291.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.95,90,,327.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.44,32.15,,117.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,146.44,32.15,,117.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,400.84,88,,320.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,150.82,33.11,,120.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.44,409.95,
APPLY LONG ARM CAST,1429065,CDM,450,RC,29065,HCPCS,Outpatient,,,456.5,273.9,,388.03,85,,310.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.34,80.03,,292.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,410.85,90,,328.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.72,88,,321.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.15,33.11,,120.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.76,410.85,
APPLY SHORT ARM CAST,1429075,CDM,450,RC,29075,HCPCS,Outpatient,,,456.5,273.9,,388.03,85,,310.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.34,80.03,,292.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,410.85,90,,328.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.72,88,,321.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.15,33.11,,120.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.76,410.85,
APPLY SHORT LEG CAST (KNEE TO TOES),1429405,CDM,450,RC,29405,HCPCS,Outpatient,,,456.5,273.9,,388.03,85,,310.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.34,80.03,,292.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,410.85,90,,328.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.72,88,,321.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.15,33.11,,120.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.76,410.85,
APPLY SHORT LEG WALKING CAST,1429425,CDM,450,RC,29425,HCPCS,Outpatient,,,456.5,273.9,,388.03,85,,310.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.34,80.03,,292.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,410.85,90,,328.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.72,88,,321.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.15,33.11,,120.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.76,410.85,
REMOVAL OR BIVALVING CAST,1429700,CDM,450,RC,29700,HCPCS,Outpatient,,,456.5,273.9,,388.03,85,,310.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.34,80.03,,292.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,410.85,90,,328.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.72,88,,321.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.15,33.11,,120.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.76,410.85,
"REMOV/BIVALV LNG A,L CAST",1429705,CDM,450,RC,29705,HCPCS,Outpatient,,,456.5,273.9,,388.03,85,,310.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.34,80.03,,292.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,410.85,90,,328.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.72,88,,321.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.15,33.11,,120.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.76,410.85,
RETRIEVER SUTURE HOFFEE,4999039,CDM,270,RC,,,Outpatient,,,456.75,274.05,,388.24,85,,310.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.54,80.03,,292.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,411.08,90,,328.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.94,88,,321.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.23,33.11,,120.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.85,411.08,
"O/T WRIST, FINGER,HAND ORTHOSIS RESTING",3940,CDM,274,RC,L3808,HCPCS,Outpatient,,,456.75,274.05,,388.24,85,,310.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.54,80.03,,292.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,411.08,90,,328.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.94,88,,321.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.23,33.11,,120.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.85,411.08,
TM JOINTS BILAT,22302,CDM,320,RC,70330,HCPCS,Outpatient,,,456.75,274.05,,388.24,85,,310.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.54,80.03,,292.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,411.08,90,,328.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,146.85,32.15,,117.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.94,88,,321.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.23,33.11,,120.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.85,411.08,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",22114,CDM,320,RC,76000,HCPCS,Outpatient,,,457.25,274.35,,388.66,85,,310.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.94,80.03,,292.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,411.53,90,,329.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.38,88,,321.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.4,33.11,,121.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.01,411.53,
BONE/JOINT TOMOGRAPHIC (SPECT),2378320,CDM,341,RC,78320,HCPCS,Outpatient,,,457.25,274.35,,388.66,85,,310.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.94,80.03,,292.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,411.53,90,,329.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.38,88,,321.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.4,33.11,,121.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.01,411.53,
Ultrasound of back wall of the abdomen with limited areas viewed,24013,CDM,402,RC,76775,HCPCS,Outpatient,,,457.25,274.35,,388.66,85,,310.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.94,80.03,,292.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,411.53,90,,329.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.38,88,,321.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.4,33.11,,121.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.01,411.53,
Transrectal ultrasound,24091,CDM,402,RC,76872,HCPCS,Outpatient,,,457.25,274.35,,388.66,85,,310.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.94,80.03,,292.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,411.53,90,,329.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.38,88,,321.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.4,33.11,,121.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.01,411.53,
US MESENTARY,24126,CDM,921,RC,93976,HCPCS,Outpatient,,,457.25,274.35,,388.66,85,,310.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.94,80.03,,292.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,411.53,90,,329.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,147.01,32.15,,117.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.38,88,,321.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.4,33.11,,121.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.01,411.53,
RHOGAM,2086273,CDM,300,RC,86902,HCPCS,Outpatient,,,457.36,274.42,,388.76,85,,311.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,366.03,80.03,,292.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,411.62,90,,329.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,4.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,402.48,88,,321.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.3,411.62,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",11102,CDM,761,RC,11102,HCPCS,Outpatient,,,457.5,274.5,,388.88,85,,311.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.14,80.03,,292.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,411.75,90,,329.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.6,88,,322.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.48,33.11,,121.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.09,411.75,
PUNCH BIOPSY OF SKIN SINGLE LESION,11104,CDM,761,RC,11104,HCPCS,Outpatient,,,457.5,274.5,,388.88,85,,311.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.14,80.03,,292.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,411.75,90,,329.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.6,88,,322.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.48,33.11,,121.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.09,411.75,
INCISIONAL BIOPSY OF SKIN SINGLE LESION,11106,CDM,761,RC,11106,HCPCS,Outpatient,,,457.5,274.5,,388.88,85,,311.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.14,80.03,,292.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,411.75,90,,329.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,147.09,32.15,,117.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.6,88,,322.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.48,33.11,,121.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.09,411.75,
HYPERBARIC O2 PER 30 MINUTES,8401300,CDM,413,RC,G0277,HCPCS,Outpatient,,,459.06,275.44,,390.2,85,,312.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.59,32.15,,118.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,367.39,80.03,,293.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,119.89,102,,,fee schedule,Pays at 102% of CMS APC rate,413.15,90,,330.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.59,32.15,,118.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.89,100,,,fee schedule,Pays at 100% of CMS APC rate,147.59,32.15,,118.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,403.97,88,,323.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.99,33.11,,121.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.59,413.15,
Blood test to determine genetic material of certain infectious agents,1886613,CDM,300,RC,87801,HCPCS,Outpatient,,,459.5,275.7,,390.58,85,,312.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,367.74,80.03,,294.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.6,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,413.55,90,,330.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,71.6,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,49.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,404.36,88,,323.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.82,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,49.34,413.55,
Test of tissues for diagnosis of abnormalities,2188387,CDM,310,RC,88305,HCPCS,Outpatient,,,459.5,275.7,,390.58,85,,312.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,367.74,80.03,,294.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,413.55,90,,330.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,404.36,88,,323.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,65.88,413.55,
MATTRESS ROTATING,49006,CDM,270,RC,,,Outpatient,,,460.75,276.45,,391.64,85,,313.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,148.13,32.15,,118.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,368.74,80.03,,294.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,414.68,90,,331.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,148.13,32.15,,118.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,148.13,32.15,,118.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,405.46,88,,324.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,152.55,33.11,,122.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,148.13,414.68,
RENTAL OPTIFLEX III KNEE CPM,49015,CDM,270,RC,,,Outpatient,,,460.75,276.45,,391.64,85,,313.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,148.13,32.15,,118.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,368.74,80.03,,294.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,414.68,90,,331.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,148.13,32.15,,118.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,148.13,32.15,,118.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,405.46,88,,324.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,152.55,33.11,,122.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,148.13,414.68,
RESP THERAPY INTUBATION,30310,CDM,410,RC,31500,HCPCS,Outpatient,,,461.5,276.9,,392.28,85,,313.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,148.37,32.15,,118.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.34,80.03,,295.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,415.35,90,,332.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,148.37,32.15,,118.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,148.37,32.15,,118.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,406.12,88,,324.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,152.8,33.11,,122.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,148.37,415.35,
ENDOTRACH INTUBATION,1431500,CDM,450,RC,31500,HCPCS,Outpatient,,,461.5,276.9,,392.28,85,,313.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,148.37,32.15,,118.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.34,80.03,,295.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,415.35,90,,332.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,148.37,32.15,,118.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,148.37,32.15,,118.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,406.12,88,,324.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,152.8,33.11,,122.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,148.37,415.35,
APP LOW COST SKIN SUB GRAFT ADD 25CM,8415272,CDM,761,RC,15272,HCPCS,Outpatient,,,462.5,277.5,,393.13,85,,314.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,148.69,32.15,,118.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,370.14,80.03,,296.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.25,90,,333,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,148.69,32.15,,118.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,148.69,32.15,,118.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,407,88,,325.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,153.13,33.11,,122.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,148.69,416.25,
APP LOW COST SKIN SUB GRAFT ADD 25CM,8415276,CDM,761,RC,15276,HCPCS,Outpatient,,,462.5,277.5,,393.13,85,,314.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,148.69,32.15,,118.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,370.14,80.03,,296.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.25,90,,333,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,148.69,32.15,,118.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,148.69,32.15,,118.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,407,88,,325.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,153.13,33.11,,122.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,148.69,416.25,
PROLONGED DETENTION EA ADD HR,1499151,CDM,450,RC,,,Outpatient,,,463.75,278.25,,394.19,85,,315.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.1,32.15,,119.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,371.14,80.03,,296.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,417.38,90,,333.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.1,32.15,,119.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,149.1,32.15,,119.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,408.1,88,,326.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,153.55,33.11,,122.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.1,417.38,
S/T EVAL FLUENCY (Stuttering/Cluttering),3292521,CDM,440,RC,92521,HCPCS,Outpatient,,,464.75,278.85,,395.04,85,,316.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,371.94,80.03,,297.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,130.07,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,418.28,90,,334.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.07,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,408.98,88,,327.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,153.88,33.11,,123.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.42,418.28,
PORT GALLBLADDER ORAL CONTRAST,22222,CDM,320,RC,74290,HCPCS,Outpatient,,,464.95,278.97,,395.21,85,,316.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.48,32.15,,119.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.1,80.03,,297.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,418.46,90,,334.77,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.48,32.15,,119.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,149.48,32.15,,119.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.16,88,,327.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,153.94,33.11,,123.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.48,418.46,
"Emergency department visit, moderately severe problem",14007,CDM,450,RC,99283,HCPCS,Outpatient,,,465.15,279.09,,395.38,85,,316.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.26,80.03,,297.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,234.91,102,,,fee schedule,Pays at 102% of CMS APC rate,418.64,90,,334.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.33,88,,327.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,372.26,418.64,
"Emergency department visit, moderately severe problem",14019,CDM,450,RC,99283,HCPCS,Outpatient,,,465.15,279.09,,395.38,85,,316.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.26,80.03,,297.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,234.91,102,,,fee schedule,Pays at 102% of CMS APC rate,418.64,90,,334.91,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.33,88,,327.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,372.26,418.64,
FISH EA MULTIPLEX STAIN   (CSI),2188186,CDM,310,RC,88377,HCPCS,Outpatient,,,465.75,279.45,,395.89,85,,316.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,181.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,372.74,80.03,,298.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,419.18,90,,335.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,181.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,181.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,409.86,88,,327.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,187.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,181.64,419.18,
VCUG,22102,CDM,320,RC,74455,HCPCS,Outpatient,,,465.75,279.45,,395.89,85,,316.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.74,80.03,,298.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,419.18,90,,335.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.86,88,,327.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.21,33.11,,123.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.74,419.18,
ARTHROGRAM SHOULDER LT,22130,CDM,320,RC,73040,HCPCS,Outpatient,,,465.75,279.45,,395.89,85,,316.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.74,80.03,,298.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,419.18,90,,335.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.86,88,,327.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.21,33.11,,123.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.74,419.18,
ARTHROGRAM SHOULDER RT,22272,CDM,320,RC,73040,HCPCS,Outpatient,,,465.75,279.45,,395.89,85,,316.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.74,80.03,,298.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,419.18,90,,335.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.86,88,,327.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.21,33.11,,123.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.74,419.18,
CHEST TUBE FOR DRAINAGE,4006,CDM,360,RC,32000,HCPCS,Outpatient,,,466.25,279.75,,396.31,85,,317.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.9,32.15,,119.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.14,80.03,,298.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,419.63,90,,335.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.9,32.15,,119.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,149.9,32.15,,119.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,410.3,88,,328.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.38,33.11,,123.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.9,419.63,
O/T ULNAR NERVE OR MCP FLEXION SPLINTORT,3943,CDM,430,RC,L3805,HCPCS,Outpatient,,,467,280.2,,396.95,85,,317.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.14,32.15,,120.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.74,80.03,,298.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420.3,90,,336.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.14,32.15,,120.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,150.14,32.15,,120.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,410.96,88,,328.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.62,33.11,,123.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.14,420.3,
BLADE GATOR 3.5MM MICRO,49233,CDM,270,RC,,,Outpatient,,,467.25,280.35,,397.16,85,,317.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.94,80.03,,299.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420.53,90,,336.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.18,88,,328.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.71,33.11,,123.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.22,420.53,
BLADE BURR SPHERICAL 2.9MM MICRO,49236,CDM,270,RC,,,Outpatient,,,467.25,280.35,,397.16,85,,317.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.94,80.03,,299.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420.53,90,,336.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.18,88,,328.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.71,33.11,,123.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.22,420.53,
BLADE BURR SPHERICAL 3.5MM MICRO,49238,CDM,270,RC,,,Outpatient,,,467.25,280.35,,397.16,85,,317.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.94,80.03,,299.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420.53,90,,336.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,150.22,32.15,,120.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.18,88,,328.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.71,33.11,,123.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.22,420.53,
SURGICEL 2 X 3,493346,CDM,270,RC,,,Outpatient,,,467.5,280.5,,397.38,85,,317.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.3,32.15,,120.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,374.14,80.03,,299.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420.75,90,,336.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.3,32.15,,120.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,150.3,32.15,,120.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.4,88,,329.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.79,33.11,,123.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.3,420.75,
"JC VIRUS DNA, QT PCR  (MAYO)",1887497,CDM,300,RC,87799,HCPCS,Outpatient,,,468,280.8,,397.8,85,,318.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.46,32.15,,120.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,374.54,80.03,,299.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,43.69,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,421.2,90,,336.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.46,32.15,,120.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.69,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,150.46,32.15,,120.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.84,88,,329.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.95,33.11,,123.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.46,421.2,
THIOPURINE   (MAYO),1880291,CDM,300,RC,82657,HCPCS,Outpatient,,,468.25,280.95,,398.01,85,,318.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,374.74,80.03,,299.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,22.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,421.43,90,,337.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,22.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,412.06,88,,329.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,421.43,
BLS EMERGENCY TRANSPORT,530322,CDM,540,RC,A0429,HCPCS,Outpatient,,,470.45,282.27,,399.88,85,,319.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.25,32.15,,121,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.5,80.03,,301.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,423.41,90,,338.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.25,32.15,,121,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,151.25,32.15,,121,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414,88,,331.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.77,33.11,,124.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,151.25,423.41,
BLS EMERGENCY TRANSPORT,530429,CDM,540,RC,A0429,HCPCS,Outpatient,,,470.45,282.27,,399.88,85,,319.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.25,32.15,,121,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.5,80.03,,301.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,423.41,90,,338.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.25,32.15,,121,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,151.25,32.15,,121,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414,88,,331.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.77,33.11,,124.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,151.25,423.41,
PARING/ CUT BENIGN HYPER LESION OVER 4,11057,CDM,761,RC,11055,HCPCS,Outpatient,,,471,282.6,,400.35,85,,320.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.94,80.03,,301.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,423.9,90,,339.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.48,88,,331.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.95,33.11,,124.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,151.43,423.9,
"EBV, PCR QT EACH  (MAYO)",1887798,CDM,300,RC,87798,HCPCS,Outpatient,,,471.25,282.75,,400.56,85,,320.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,377.14,80.03,,301.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,424.13,90,,339.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,414.7,88,,331.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,424.13,
Blood test to assist with diagnosis,2188389,CDM,310,RC,88313,HCPCS,Outpatient,,,473,283.8,,402.05,85,,321.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,378.54,80.03,,302.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,425.7,90,,340.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,416.24,88,,332.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.91,425.7,
SKELETAL SURVEY,22269,CDM,320,RC,77075,HCPCS,Outpatient,,,474,284.4,,402.9,85,,322.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,379.34,80.03,,303.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,426.6,90,,341.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,417.12,88,,333.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,156.94,33.11,,125.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,152.39,426.6,
US BREAST COMPLETE BILATERAL,24110,CDM,402,RC,76641,HCPCS,Outpatient,,,474,284.4,,402.9,85,,322.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,379.34,80.03,,303.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,426.6,90,,341.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,417.12,88,,333.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,156.94,33.11,,125.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,152.39,426.6,
US EXTREMITY UNILATERAL ARTERIAL,24127,CDM,921,RC,93926,HCPCS,Outpatient,,,474,284.4,,402.9,85,,322.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,379.34,80.03,,303.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,426.6,90,,341.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,152.39,32.15,,121.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,417.12,88,,333.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,156.94,33.11,,125.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,152.39,426.6,
SPINAL-INC.MTR&SUP (OR),13015,CDM,370,RC,,,Outpatient,,,474.06,284.44,,402.95,85,,322.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,152.41,32.15,,121.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,379.39,80.03,,303.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.65,90,,341.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,152.41,32.15,,121.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,152.41,32.15,,121.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,417.17,88,,333.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,156.96,33.11,,125.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,152.41,426.65,
NASAL PACKING BILATERAL,1430910,CDM,450,RC,30901,HCPCS,Outpatient,,,475,285,,403.75,85,,323,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,152.71,32.15,,122.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,380.14,80.03,,304.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,427.5,90,,342,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,152.71,32.15,,122.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,152.71,32.15,,122.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,418,88,,334.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,157.27,33.11,,125.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,152.71,427.5,
KRAS MUTATION PANEL,2183896,CDM,300,RC,88361,HCPCS,Outpatient,,,477.25,286.35,,405.66,85,,324.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,381.94,80.03,,305.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,429.53,90,,343.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,122.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,419.98,88,,335.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,125.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,122.28,429.53,
MM DIGITAL  MAMMO NEEDLE LOC 2ND LESION,19282,CDM,320,RC,19282,HCPCS,Outpatient,,,477.25,286.35,,405.66,85,,324.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.44,32.15,,122.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,381.94,80.03,,305.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,429.53,90,,343.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.44,32.15,,122.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,153.44,32.15,,122.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,419.98,88,,335.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.02,33.11,,126.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.44,429.53,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",290085,CDM,260,RC,96365,HCPCS,Outpatient,,,478,286.8,,406.3,85,,325.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.68,32.15,,122.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,382.54,80.03,,306.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,430.2,90,,344.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.68,32.15,,122.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,153.68,32.15,,122.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,420.64,88,,336.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.27,33.11,,126.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.68,430.2,
Injection of medication into an area that triggers pain,1420550,CDM,450,RC,20553,HCPCS,Outpatient,,,478.25,286.95,,406.51,85,,325.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,382.74,80.03,,306.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,430.43,90,,344.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,420.86,88,,336.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.35,33.11,,126.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.76,430.43,
Draining or injecting medication into a small joint/bursa without ultrasound,1420600,CDM,450,RC,20600,HCPCS,Outpatient,,,478.25,286.95,,406.51,85,,325.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,382.74,80.03,,306.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,430.43,90,,344.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,420.86,88,,336.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.35,33.11,,126.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.76,430.43,
Draining or injecting medication into a large joint/bursa without ultrasound,1420605,CDM,450,RC,20605,HCPCS,Outpatient,,,478.25,286.95,,406.51,85,,325.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,382.74,80.03,,306.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,430.43,90,,344.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,420.86,88,,336.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.35,33.11,,126.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.76,430.43,
NERVE BLOCK TRIGEMINAL,1464400,CDM,450,RC,64400,HCPCS,Outpatient,,,478.25,286.95,,406.51,85,,325.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,382.74,80.03,,306.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,430.43,90,,344.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,153.76,32.15,,123.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,420.86,88,,336.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.35,33.11,,126.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.76,430.43,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",22110,CDM,320,RC,76000,HCPCS,Outpatient,,,478.75,287.25,,406.94,85,,325.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.92,32.15,,123.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,383.14,80.03,,306.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,430.88,90,,344.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.92,32.15,,123.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,153.92,32.15,,123.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,421.3,88,,337.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.51,33.11,,126.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.92,430.88,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24009,CDM,402,RC,76705,HCPCS,Outpatient,,,478.75,287.25,,406.94,85,,325.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,153.92,32.15,,123.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,383.14,80.03,,306.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,430.88,90,,344.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,153.92,32.15,,123.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,153.92,32.15,,123.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,421.3,88,,337.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.51,33.11,,126.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,153.92,430.88,
HIV-1 DNA & RNA QL PCR  (MAYO),1883895,CDM,300,RC,87535,HCPCS,Outpatient,,,479.25,287.55,,407.36,85,,325.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,383.54,80.03,,306.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,431.33,90,,345.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,421.74,88,,337.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,431.33,
Test to determine if wheezing is present,1494060,CDM,450,RC,94060,HCPCS,Outpatient,,,480.25,288.15,,408.21,85,,326.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,154.4,32.15,,123.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,80.03,,307.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.48,102,,,fee schedule,Pays at 102% of CMS APC rate,432.23,90,,345.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,154.4,32.15,,123.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.48,100,,,fee schedule,Pays at 100% of CMS APC rate,154.4,32.15,,123.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,422.62,88,,338.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.01,33.11,,127.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154.4,432.23,
GLUTAMIC ACID  (MAYO),1884239,CDM,300,RC,86341,HCPCS,Outpatient,,,481,288.6,,408.85,85,,327.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,384.94,80.03,,307.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.04,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,432.9,90,,346.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.04,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.89,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,423.28,88,,338.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.89,432.9,
BLADE GATOR 2.9MM MICRO,49231,CDM,270,RC,,,Outpatient,,,481.5,288.9,,409.28,85,,327.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,154.8,32.15,,123.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.34,80.03,,308.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,433.35,90,,346.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,154.8,32.15,,123.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,154.8,32.15,,123.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,423.72,88,,338.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.42,33.11,,127.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154.8,433.35,
S/T EVAL III,3220013,CDM,440,RC,92506,HCPCS,Outpatient,,,481.5,288.9,,409.28,85,,327.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,154.8,32.15,,123.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.34,80.03,,308.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,433.35,90,,346.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,154.8,32.15,,123.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,154.8,32.15,,123.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,423.72,88,,338.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.42,33.11,,127.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154.8,433.35,
INCENTIVE SPIROMETRY,30020,CDM,410,RC,94640,HCPCS,Outpatient,,,482.25,289.35,,409.91,85,,327.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.94,80.03,,308.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,434.03,90,,347.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.38,88,,339.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.67,33.11,,127.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.04,434.03,
PATIENT EVALUATION,30133,CDM,410,RC,94664,HCPCS,Outpatient,,,482.25,289.35,,409.91,85,,327.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.94,80.03,,308.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,434.03,90,,347.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.38,88,,339.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.67,33.11,,127.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.04,434.03,
SPUTUM INDUCTION,30250,CDM,410,RC,94640,HCPCS,Outpatient,,,482.25,289.35,,409.91,85,,327.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.94,80.03,,308.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,434.03,90,,347.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.38,88,,339.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.67,33.11,,127.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.04,434.03,
SUCTION OUTPATIENT,30324,CDM,410,RC,31720,HCPCS,Outpatient,,,482.25,289.35,,409.91,85,,327.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.94,80.03,,308.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,434.03,90,,347.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.38,88,,339.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.67,33.11,,127.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.04,434.03,
MECHANICAL CHEST WALL  OSCOILL,3094669,CDM,410,RC,94669,HCPCS,Outpatient,,,482.25,289.35,,409.91,85,,327.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,385.94,80.03,,308.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,434.03,90,,347.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,155.04,32.15,,124.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.38,88,,339.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.67,33.11,,127.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.04,434.03,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",1496365,CDM,260,RC,96365,HCPCS,Outpatient,,,484.5,290.7,,411.83,85,,329.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.75,80.03,,310.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,436.05,90,,348.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,426.36,88,,341.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,160.42,33.11,,128.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.77,436.05,
S/T MBS (SLP EVALUATION),322003,CDM,440,RC,92611,HCPCS,Outpatient,,,484.5,290.7,,411.83,85,,329.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.75,80.03,,310.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,89.02,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,436.05,90,,348.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.02,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,426.36,88,,341.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,160.42,33.11,,128.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.77,436.05,
NEG PRESSURE WOUND THERAPY VACUUM ASSIST,97606,CDM,761,RC,97606,HCPCS,Outpatient,,,487.75,292.65,,414.59,85,,331.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.35,80.03,,312.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,438.98,90,,351.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.22,88,,343.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.49,33.11,,129.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,156.81,438.98,
DRESS AND/OR DEBRIDE PARTIAL BURN MEDIUM,8416025,CDM,761,RC,16025,HCPCS,Outpatient,,,487.75,292.65,,414.59,85,,331.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.35,80.03,,312.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,438.98,90,,351.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.22,88,,343.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.49,33.11,,129.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,156.81,438.98,
DRESS AND/OR DEBRIDE PARTIAL BURN LARGE,8416030,CDM,761,RC,16030,HCPCS,Outpatient,,,487.75,292.65,,414.59,85,,331.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.35,80.03,,312.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,438.98,90,,351.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,156.81,32.15,,125.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.22,88,,343.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.49,33.11,,129.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,156.81,438.98,
US THORAX AND PLEURA,24003,CDM,402,RC,76604,HCPCS,Outpatient,,,488.5,293.1,,415.23,85,,332.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.95,80.03,,312.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,439.65,90,,351.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.88,88,,343.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.74,33.11,,129.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,157.05,439.65,
US CHEST FOR FLUID,24025,CDM,402,RC,76942,HCPCS,Outpatient,,,488.5,293.1,,415.23,85,,332.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.95,80.03,,312.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,439.65,90,,351.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,488.5,,,,Other,Not Separately reimbursable,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.88,88,,343.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.74,33.11,,129.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,157.05,439.65,
US CYST ASPIRATION,24026,CDM,402,RC,76942,HCPCS,Outpatient,,,488.5,293.1,,415.23,85,,332.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.95,80.03,,312.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,439.65,90,,351.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,488.5,,,,Other,Not Separately reimbursable,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.88,88,,343.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.74,33.11,,129.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,157.05,439.65,
Ultrasound of head and neck,24059,CDM,402,RC,76536,HCPCS,Outpatient,,,488.5,293.1,,415.23,85,,332.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.95,80.03,,312.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,439.65,90,,351.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.88,88,,343.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.74,33.11,,129.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,157.05,439.65,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24135,CDM,402,RC,76705,HCPCS,Outpatient,,,488.5,293.1,,415.23,85,,332.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.95,80.03,,312.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,439.65,90,,351.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.88,88,,343.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.74,33.11,,129.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,157.05,439.65,
UROSTOMY POST-OP 1 3/4,493219,CDM,270,RC,,,Outpatient,,,490,294,,416.5,85,,333.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,157.54,32.15,,126.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,392.15,80.03,,313.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441,90,,352.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,157.54,32.15,,126.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490,,,,Other,Not Separately reimbursable,157.54,32.15,,126.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,431.2,88,,344.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,162.24,33.11,,129.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,157.54,441,
ELECTRODE QUIK-COMBO ADULT PHYSIO,49086,CDM,270,RC,,,Outpatient,,,491.75,295.05,,417.99,85,,334.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,393.55,80.03,,314.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,442.58,90,,354.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,491.75,,,,Other,Not Separately reimbursable,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,432.74,88,,346.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,162.82,33.11,,130.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,158.1,442.58,
ELECTRODE MULTI-FUNCTION ADULT ZOLL CONN,49100,CDM,270,RC,,,Outpatient,,,491.75,295.05,,417.99,85,,334.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,393.55,80.03,,314.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,442.58,90,,354.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,491.75,,,,Other,Not Separately reimbursable,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,432.74,88,,346.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,162.82,33.11,,130.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,158.1,442.58,
Test of tissues for diagnosis of abnormalities,2188383,CDM,300,RC,88305,HCPCS,Outpatient,,,491.75,295.05,,417.99,85,,334.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,393.55,80.03,,314.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,442.58,90,,354.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,432.74,88,,346.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,65.88,442.58,
Test of tissues for diagnosis of abnormalities,2188356,CDM,310,RC,88305,HCPCS,Outpatient,,,491.75,295.05,,417.99,85,,334.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,393.55,80.03,,314.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,442.58,90,,354.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,432.74,88,,346.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,65.88,442.58,
PELVIS 5 OR MORE VIEWS,22523,CDM,320,RC,72190,HCPCS,Outpatient,,,491.75,295.05,,417.99,85,,334.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,393.55,80.03,,314.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,442.58,90,,354.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,158.1,32.15,,126.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,432.74,88,,346.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,162.82,33.11,,130.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,158.1,442.58,
PYRIMIDINE 5 NUCLEOTIDASE  (MAYO),1883915,CDM,300,RC,83915,HCPCS,Outpatient,,,492.25,295.35,,418.41,85,,334.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,393.95,80.03,,315.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,11.37,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,443.03,90,,354.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11.37,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,14.02,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,433.18,88,,346.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.44,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.02,443.03,
NM GALLIUM KIT,2932298,CDM,636,RC,A9556,HCPCS,Outpatient,,,493.63,296.18,,419.59,85,,335.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,158.7,32.15,,126.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,395.05,80.03,,316.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,444.27,90,,355.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,158.7,32.15,,126.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,493.63,,,,Other,Not Separately reimbursable,158.7,32.15,,126.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,434.39,88,,347.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,163.44,33.11,,130.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,158.7,444.27,
GLUCAGON 1MG INJ,293231,CDM,636,RC,J1610,HCPCS,Outpatient,,,494.21,296.53,,420.08,85,,336.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,187.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,395.52,80.03,,316.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,191.25,102,,,fee schedule,Pays at 102% of CMS APC rate,444.79,90,,355.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,187.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,191.25,100,,,fee schedule,Pays at 100% of CMS APC rate,187.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,434.9,88,,347.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,193.13,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,187.5,444.79,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",4009,CDM,260,RC,96374,HCPCS,Outpatient,,,494.75,296.85,,420.54,85,,336.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,395.95,80.03,,316.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,445.28,90,,356.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,435.38,88,,348.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,163.81,33.11,,131.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,159.06,445.28,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",11014,CDM,260,RC,96374,HCPCS,Outpatient,,,494.75,296.85,,420.54,85,,336.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,395.95,80.03,,316.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,445.28,90,,356.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,435.38,88,,348.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,163.81,33.11,,131.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,159.06,445.28,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",1490784,CDM,260,RC,96374,HCPCS,Outpatient,,,494.75,296.85,,420.54,85,,336.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,395.95,80.03,,316.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.03,102,,,fee schedule,Pays at 102% of CMS APC rate,445.28,90,,356.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.03,100,,,fee schedule,Pays at 100% of CMS APC rate,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,435.38,88,,348.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,163.81,33.11,,131.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,159.06,445.28,
NM MYOCARDIAL SINGLE PERFUSION STUDY,2378480,CDM,341,RC,78451,HCPCS,Outpatient,,,498,298.8,,423.3,85,,338.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,160.11,32.15,,128.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,398.55,80.03,,318.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,448.2,90,,358.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,160.11,32.15,,128.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,160.11,32.15,,128.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.24,88,,350.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,164.89,33.11,,131.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,160.11,448.2,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24056,CDM,402,RC,76705,HCPCS,Outpatient,,,498,298.8,,423.3,85,,338.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,160.11,32.15,,128.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,398.55,80.03,,318.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,448.2,90,,358.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,160.11,32.15,,128.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,160.11,32.15,,128.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.24,88,,350.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,164.89,33.11,,131.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,160.11,448.2,
ARTHROGRAM HIP RIGHT,22210,CDM,320,RC,73525,HCPCS,Outpatient,,,500,300,,425,85,,340,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,160.75,32.15,,128.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,400.15,80.03,,320.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,450,90,,360,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,160.75,32.15,,128.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,160.75,32.15,,128.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,440,88,,352,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,165.55,33.11,,132.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,160.75,450,
EACH ADDITIONAL HOUR,10010,CDM,710,RC,,,Outpatient,,,502.19,301.31,,426.86,85,,341.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,161.45,32.15,,129.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.9,80.03,,321.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,451.97,90,,361.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,161.45,32.15,,129.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.19,,,,Other,Not Separately reimbursable,161.45,32.15,,129.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,441.93,88,,353.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,166.28,33.11,,133.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,161.45,451.97,
EMEND (fosaprepitant) 150MG INJ,29624,CDM,636,RC,J1453,HCPCS,Outpatient,,,505.75,303.45,,429.89,85,,343.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,404.75,80.03,,323.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455.18,90,,364.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,505.75,,,,Other,Not Separately reimbursable,0.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,445.06,88,,356.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.12,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.12,455.18,
FORCEP LG CAP II SERRATED DISTAL SHEATH,4988022,CDM,270,RC,,,Outpatient,,,508,304.8,,431.8,85,,345.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,163.32,32.15,,130.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,406.55,80.03,,325.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.2,90,,365.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,163.32,32.15,,130.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508,,,,Other,Not Separately reimbursable,163.32,32.15,,130.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,447.04,88,,357.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,168.2,33.11,,134.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,163.32,457.2,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24008,CDM,402,RC,76705,HCPCS,Outpatient,,,508,304.8,,431.8,85,,345.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,163.32,32.15,,130.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,406.55,80.03,,325.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,457.2,90,,365.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,163.32,32.15,,130.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,163.32,32.15,,130.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,447.04,88,,357.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,168.2,33.11,,134.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,163.32,457.2,
PATHOLOGY FROZEN SECTION CONSULT,2188331,CDM,310,RC,88331,HCPCS,Outpatient,,,508.25,304.95,,432.01,85,,345.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,406.75,80.03,,325.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,457.43,90,,365.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,447.26,88,,357.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,74.76,457.43,
PACK DELIVERY VAGINAL,491840,CDM,270,RC,,,Outpatient,,,508.75,305.25,,432.44,85,,345.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,163.56,32.15,,130.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,407.15,80.03,,325.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.88,90,,366.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,163.56,32.15,,130.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.75,,,,Other,Not Separately reimbursable,163.56,32.15,,130.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,447.7,88,,358.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,168.45,33.11,,134.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,163.56,457.88,
10 GUAGE NEEDLE,27094,CDM,270,RC,,,Outpatient,,,511.25,306.75,,434.56,85,,347.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,164.37,32.15,,131.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.15,80.03,,327.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,460.13,90,,368.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,164.37,32.15,,131.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,511.25,,,,Other,Not Separately reimbursable,164.37,32.15,,131.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,449.9,88,,359.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,169.27,33.11,,135.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,164.37,460.13,
BLOOD ADMINISTRATION FEE,2036430,CDM,381,RC,36430,HCPCS,Outpatient,,,512,307.2,,435.2,85,,348.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,164.61,32.15,,131.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.75,80.03,,327.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,390.9,102,,,fee schedule,Pays at 102% of CMS APC rate,460.8,90,,368.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,164.61,32.15,,131.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.9,100,,,fee schedule,Pays at 100% of CMS APC rate,164.61,32.15,,131.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,450.56,88,,360.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,169.52,33.11,,135.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,164.61,460.8,
RIFAMPIN 600MG VIAL,293598,CDM,250,RC,J3490,HCPCS,Outpatient,,,513.6,308.16,,436.56,85,,349.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.12,32.15,,132.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.03,80.03,,328.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462.24,90,,369.79,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.12,32.15,,132.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,513.6,,,,Other,Not Separately reimbursable,165.12,32.15,,132.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,451.97,88,,361.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.05,33.11,,136.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.12,462.24,
NEPHROSTOMY TUBE PLACEMENT BILAT,750392,CDM,450,RC,50432,HCPCS,Outpatient,,,514.25,308.55,,437.11,85,,349.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.33,32.15,,132.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.55,80.03,,329.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1778.27,102,,,fee schedule,Pays at 102% of CMS APC rate,462.83,90,,370.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.33,32.15,,132.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1778.27,100,,,fee schedule,Pays at 100% of CMS APC rate,165.33,32.15,,132.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,452.54,88,,362.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.27,33.11,,136.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.33,462.83,
RINGS RETRACTOR,490163,CDM,270,RC,,,Outpatient,,,514.5,308.7,,437.33,85,,349.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.41,32.15,,132.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.75,80.03,,329.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.05,90,,370.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.41,32.15,,132.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,514.5,,,,Other,Not Separately reimbursable,165.41,32.15,,132.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,452.76,88,,362.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.35,33.11,,136.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.41,463.05,
Radiologic examination of the shoulder,22600,CDM,320,RC,73030,HCPCS,Outpatient,,,514.5,308.7,,437.33,85,,349.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.41,32.15,,132.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.75,80.03,,329.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,463.05,90,,370.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.41,32.15,,132.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,165.41,32.15,,132.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,452.76,88,,362.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.35,33.11,,136.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.41,463.05,
I AND D ABSCESS COMPLICATED/MULTIPLE,10061,CDM,761,RC,10061,HCPCS,Outpatient,,,515.5,309.3,,438.18,85,,350.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.73,32.15,,132.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,412.55,80.03,,330.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,463.95,90,,371.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.73,32.15,,132.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,165.73,32.15,,132.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,453.64,88,,362.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.68,33.11,,136.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.73,463.95,
SET THORACENTESIS 15G BOTTLE NEEDLE 30,496376,CDM,270,RC,,,Outpatient,,,516.25,309.75,,438.81,85,,351.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.97,32.15,,132.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,413.15,80.03,,330.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,464.63,90,,371.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.97,32.15,,132.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,516.25,,,,Other,Not Separately reimbursable,165.97,32.15,,132.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,454.3,88,,363.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.93,33.11,,136.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.97,464.63,
NEEDLE 5FR 10CM DTVN STRAIGHT YUEH CATH,496378,CDM,270,RC,,,Outpatient,,,516.25,309.75,,438.81,85,,351.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.97,32.15,,132.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,413.15,80.03,,330.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,464.63,90,,371.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.97,32.15,,132.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,516.25,,,,Other,Not Separately reimbursable,165.97,32.15,,132.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,454.3,88,,363.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.93,33.11,,136.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.97,464.63,
ARTHROGRAM WRIST RT,22060,CDM,320,RC,73115,HCPCS,Outpatient,,,517.5,310.5,,439.88,85,,351.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.16,80.03,,331.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,465.75,90,,372.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,455.4,88,,364.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.34,33.11,,137.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.38,465.75,
ARTHROGRAM HIP LT,22066,CDM,320,RC,73525,HCPCS,Outpatient,,,517.5,310.5,,439.88,85,,351.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.16,80.03,,331.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,465.75,90,,372.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,455.4,88,,364.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.34,33.11,,137.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.38,465.75,
REGIONAL BLOCK (OR),13025,CDM,370,RC,,,Outpatient,,,517.5,310.5,,439.88,85,,351.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.16,80.03,,331.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,465.75,90,,372.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,517.5,,,,Other,Not Separately reimbursable,166.38,32.15,,133.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,455.4,88,,364.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.34,33.11,,137.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.38,465.75,
FORCEP PRECISOR EXL CW/N OVAL,4988024,CDM,270,RC,,,Outpatient,,,518.25,310.95,,440.51,85,,352.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.76,80.03,,331.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466.43,90,,373.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,518.25,,,,Other,Not Separately reimbursable,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.06,88,,364.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.59,33.11,,137.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.62,466.43,
CO2 LASER,9050,CDM,360,RC,,,Outpatient,,,518.25,310.95,,440.51,85,,352.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.76,80.03,,331.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466.43,90,,373.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,518.25,,,,Other,Not Separately reimbursable,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.06,88,,364.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.59,33.11,,137.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.62,466.43,
Ultrasound of back wall of the abdomen with limited areas viewed,24036,CDM,402,RC,76775,HCPCS,Outpatient,,,518.25,310.95,,440.51,85,,352.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.76,80.03,,331.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,466.43,90,,373.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.06,88,,364.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.59,33.11,,137.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.62,466.43,
US ABDOMINAL AORTIC ANEURYSM SCREENING,24138,CDM,402,RC,76706,HCPCS,Outpatient,,,518.25,310.95,,440.51,85,,352.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.76,80.03,,331.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,466.43,90,,373.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,166.62,32.15,,133.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.06,88,,364.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.59,33.11,,137.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.62,466.43,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,24016,CDM,402,RC,76805,HCPCS,Outpatient,,,518.75,311.25,,440.94,85,,352.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.78,32.15,,133.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,415.16,80.03,,332.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,466.88,90,,373.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.78,32.15,,133.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,166.78,32.15,,133.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.5,88,,365.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.76,33.11,,137.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.78,466.88,
CT BIOPSY OF MUSCLE,26089,CDM,352,RC,20206,HCPCS,Outpatient,,,519.25,311.55,,441.36,85,,353.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.94,32.15,,133.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,415.56,80.03,,332.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,467.33,90,,373.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.94,32.15,,133.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,166.94,32.15,,133.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.94,88,,365.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.92,33.11,,137.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.94,467.33,
US DUPLEX HEMODIALYSIS,24119,CDM,921,RC,93990,HCPCS,Outpatient,,,519.25,311.55,,441.36,85,,353.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.94,32.15,,133.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,415.56,80.03,,332.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,467.33,90,,373.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.94,32.15,,133.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,166.94,32.15,,133.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.94,88,,365.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.92,33.11,,137.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,166.94,467.33,
ALS NONEMERGENCY TRANSPORT SPEC ALS,530326,CDM,540,RC,A0433,HCPCS,Outpatient,,,520.3,312.18,,442.26,85,,353.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,167.28,32.15,,133.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,416.4,80.03,,333.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,468.27,90,,374.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,167.28,32.15,,133.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,167.28,32.15,,133.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,457.86,88,,366.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,172.27,33.11,,137.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,167.28,468.27,
ALS NONEMERGENCY TRANSPORT SPEC ALS,530426,CDM,540,RC,A0426,HCPCS,Outpatient,,,520.3,312.18,,442.26,85,,353.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,167.28,32.15,,133.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,416.4,80.03,,333.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,468.27,90,,374.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,167.28,32.15,,133.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,167.28,32.15,,133.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,457.86,88,,366.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,172.27,33.11,,137.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,167.28,468.27,
Ultrasound of head and neck,24002,CDM,402,RC,76536,HCPCS,Outpatient,,,522.5,313.5,,444.13,85,,355.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,167.98,32.15,,134.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,418.16,80.03,,334.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,470.25,90,,376.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,167.98,32.15,,134.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,167.98,32.15,,134.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,459.8,88,,367.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,173,33.11,,138.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,167.98,470.25,
PACK D&C HYSTEROSCOPY,498541,CDM,270,RC,,,Outpatient,,,522.75,313.65,,444.34,85,,355.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,168.06,32.15,,134.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,418.36,80.03,,334.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,470.48,90,,376.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,168.06,32.15,,134.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.06,32.15,,134.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,460.02,88,,368.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,173.08,33.11,,138.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,168.06,470.48,
SLEEVE CALF COMPRESSION X-LARGE,491107,CDM,270,RC,,,Outpatient,,,523.75,314.25,,445.19,85,,356.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,168.39,32.15,,134.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,419.16,80.03,,335.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,471.38,90,,377.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,168.39,32.15,,134.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.39,32.15,,134.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,460.9,88,,368.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,173.41,33.11,,138.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,168.39,471.38,
CATHETER 6F ARTERIAL EMBOLECTOMY FOGARTY,49591,CDM,272,RC,C1757,HCPCS,Outpatient,,,524.75,314.85,,446.04,85,,356.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,168.71,32.15,,134.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,419.96,80.03,,335.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.28,90,,377.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,168.71,32.15,,134.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.71,32.15,,134.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,461.78,88,,369.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,173.74,33.11,,138.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,168.71,472.28,
TOBRAMYCIN 1.2G FOR INJECTION,293849,CDM,636,RC,J3260,HCPCS,Outpatient,,,525,315,,446.25,85,,357,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,420.16,80.03,,336.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.5,90,,378,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,2.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,462,88,,369.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2.65,472.5,
SURGICEL 2 X 14,493334,CDM,270,RC,,,Outpatient,,,525.5,315.3,,446.68,85,,357.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,168.95,32.15,,135.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,420.56,80.03,,336.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.95,90,,378.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,168.95,32.15,,135.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.95,32.15,,135.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.44,88,,369.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,173.99,33.11,,139.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,168.95,472.95,
CUROSURF (poractant) 120MG / 1.5ML,293568,CDM,250,RC,,,Outpatient,,,528,316.8,,448.8,85,,359.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,169.75,32.15,,135.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,422.56,80.03,,338.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,475.2,90,,380.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,169.75,32.15,,135.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,169.75,32.15,,135.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,464.64,88,,371.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,174.82,33.11,,139.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,169.75,475.2,
CARTRIDGE PRISM II W/BREAKOFF NOZZLE,4999057,CDM,270,RC,,,Outpatient,,,528,316.8,,448.8,85,,359.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,169.75,32.15,,135.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,422.56,80.03,,338.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,475.2,90,,380.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,169.75,32.15,,135.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,169.75,32.15,,135.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,464.64,88,,371.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,174.82,33.11,,139.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,169.75,475.2,
SET CATHETER INTRODUCER SUPRAPUBIC,49624,CDM,270,RC,,,Outpatient,,,529,317.4,,449.65,85,,359.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,170.07,32.15,,136.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,423.36,80.03,,338.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,476.1,90,,380.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,170.07,32.15,,136.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,170.07,32.15,,136.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,465.52,88,,372.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,175.15,33.11,,140.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,170.07,476.1,
ARGATROBAN 100MG INJ,293488,CDM,636,RC,C9121,HCPCS,Outpatient,,,530,318,,450.5,85,,360.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.16,80.03,,339.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477,90,,381.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,466.4,88,,373.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,175.48,33.11,,140.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,170.4,477,
US PARACENTESIS WITH IMAGING GUIDANCE,2249083,CDM,761,RC,49083,HCPCS,Outpatient,,,530,318,,450.5,85,,360.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.16,80.03,,339.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,791.41,102,,,fee schedule,Pays at 102% of CMS APC rate,477,90,,381.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,791.41,100,,,fee schedule,Pays at 100% of CMS APC rate,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,466.4,88,,373.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,175.48,33.11,,140.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,170.4,477,
AREDIA ( pamidronate) 30MG VIAL,293508,CDM,636,RC,J2430,HCPCS,Outpatient,,,530.3,318.18,,450.76,85,,360.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,10.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,424.4,80.03,,339.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.27,90,,381.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,10.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,10.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,466.66,88,,373.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,10.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10.33,477.27,
NM SESTAMIBI,23056,CDM,343,RC,A9500,HCPCS,Outpatient,,,532.5,319.5,,452.63,85,,362.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,171.2,32.15,,136.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,426.16,80.03,,340.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,479.25,90,,383.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,171.2,32.15,,136.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,171.2,32.15,,136.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,468.6,88,,374.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,176.31,33.11,,141.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,171.2,479.25,
NEUMEGA (oprelvekin) 5MG INJ,295514,CDM,636,RC,J2355,HCPCS,Outpatient,,,533,319.8,,453.05,85,,362.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,171.36,32.15,,137.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,426.56,80.03,,341.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,479.7,90,,383.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,171.36,32.15,,137.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,171.36,32.15,,137.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,469.04,88,,375.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,176.48,33.11,,141.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,171.36,479.7,
NM STRESS,2393017,CDM,482,RC,93017,HCPCS,Outpatient,,,534.38,320.63,,454.22,85,,363.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,171.8,32.15,,137.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,427.66,80.03,,342.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.49,102,,,fee schedule,Pays at 102% of CMS APC rate,480.94,90,,384.75,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,171.8,32.15,,137.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.49,100,,,fee schedule,Pays at 100% of CMS APC rate,171.8,32.15,,137.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,470.25,88,,376.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,176.93,33.11,,141.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,171.8,480.94,
DO NOT USE,3220014,CDM,440,RC,92506,HCPCS,Outpatient,,,535.75,321.45,,455.39,85,,364.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.24,32.15,,137.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,428.76,80.03,,343.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,482.18,90,,385.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.24,32.15,,137.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,172.24,32.15,,137.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,471.46,88,,377.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,177.39,33.11,,141.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.24,482.18,
CATH-BRONCHO LEFT W/CPAP 35FR,491742,CDM,270,RC,,,Outpatient,,,537.5,322.5,,456.88,85,,365.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.16,80.03,,344.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,483.75,90,,387,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473,88,,378.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,177.97,33.11,,142.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.81,483.75,
CATH-BRONCHO LEFT W/CPAP 37FR,491743,CDM,270,RC,,,Outpatient,,,537.5,322.5,,456.88,85,,365.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.16,80.03,,344.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,483.75,90,,387,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473,88,,378.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,177.97,33.11,,142.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.81,483.75,
CATH-BRONCHO LEFT W/CPAP 39FR,491744,CDM,270,RC,,,Outpatient,,,537.5,322.5,,456.88,85,,365.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.16,80.03,,344.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,483.75,90,,387,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473,88,,378.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,177.97,33.11,,142.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.81,483.75,
CATH-BRONCHO LEFT W/CPAP 41FR,491745,CDM,270,RC,,,Outpatient,,,537.5,322.5,,456.88,85,,365.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.16,80.03,,344.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,483.75,90,,387,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473,88,,378.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,177.97,33.11,,142.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.81,483.75,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24047,CDM,402,RC,76705,HCPCS,Outpatient,,,537.5,322.5,,456.88,85,,365.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.16,80.03,,344.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,483.75,90,,387,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473,88,,378.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,177.97,33.11,,142.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.81,483.75,
Ultrasound of the pelvis through vagina,24088,CDM,402,RC,76830,HCPCS,Outpatient,,,537.5,322.5,,456.88,85,,365.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.16,80.03,,344.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,483.75,90,,387,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,172.81,32.15,,138.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473,88,,378.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,177.97,33.11,,142.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.81,483.75,
CLEAN/DEBR/C ANES MED/LG,1416015,CDM,450,RC,16015,HCPCS,Outpatient,,,538,322.8,,457.3,85,,365.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,172.97,32.15,,138.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.56,80.03,,344.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,484.2,90,,387.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,172.97,32.15,,138.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,172.97,32.15,,138.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473.44,88,,378.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,178.13,33.11,,142.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,172.97,484.2,
KIT HYSTEROSCOPIC PROCEDURE,4999945,CDM,272,RC,,,Outpatient,,,538.25,322.95,,457.51,85,,366.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,173.05,32.15,,138.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.76,80.03,,344.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,484.43,90,,387.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,173.05,32.15,,138.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.05,32.15,,138.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473.66,88,,378.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,178.21,33.11,,142.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,173.05,484.43,
O/T SPREADING HAND SPLINT FIT/ADJ,3939,CDM,274,RC,L3954,HCPCS,Outpatient,,,538.5,323.1,,457.73,85,,366.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,173.13,32.15,,138.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.96,80.03,,344.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,484.65,90,,387.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,173.13,32.15,,138.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.13,32.15,,138.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473.88,88,,379.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,178.3,33.11,,142.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,173.13,484.65,
LMB AIR SOFT RESTING HAND SPLINT (PREFAB,314104,CDM,274,RC,L3954,HCPCS,Outpatient,,,538.5,323.1,,457.73,85,,366.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,173.13,32.15,,138.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.96,80.03,,344.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,484.65,90,,387.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,173.13,32.15,,138.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.13,32.15,,138.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473.88,88,,379.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,178.3,33.11,,142.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,173.13,484.65,
CHROMOSOME ANALYSIS-CONGENITAL DISORDERS,1888261,CDM,310,RC,88262,HCPCS,Outpatient,,,539.75,323.85,,458.79,85,,367.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,431.96,80.03,,345.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,127.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,485.78,90,,388.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,474.98,88,,379.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,156.73,485.78,
CT FINE NEEDLE ASPIRATION,26111,CDM,352,RC,10022,HCPCS,Outpatient,,,540.5,324.3,,459.43,85,,367.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,173.77,32.15,,139.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,432.56,80.03,,346.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.45,90,,389.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,173.77,32.15,,139.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.77,32.15,,139.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,475.64,88,,380.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,178.96,33.11,,143.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,173.77,486.45,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,22312,CDM,320,RC,62322,HCPCS,Outpatient,,,541,324.6,,459.85,85,,367.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,173.93,32.15,,139.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,432.96,80.03,,346.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,486.9,90,,389.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,173.93,32.15,,139.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,173.93,32.15,,139.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,476.08,88,,380.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,179.13,33.11,,143.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,173.93,486.9,
"DIAGNOSTIC, OUTSIDE MATRL  (JOHN HOPKIN)",2188327,CDM,310,RC,88323,HCPCS,Outpatient,,,543.25,325.95,,461.76,85,,369.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,434.76,80.03,,347.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,488.93,90,,391.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,93.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,478.06,88,,382.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.01,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,93.21,488.93,
HER2/NEU FISH-TC   (CSI),2188367,CDM,310,RC,88367,HCPCS,Outpatient,,,543.25,325.95,,461.76,85,,369.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,187.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,434.76,80.03,,347.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,488.93,90,,391.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,187.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,187.35,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,478.06,88,,382.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,192.97,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,187.35,488.93,
Ultrasound of abdomen with all areas scanned,24006,CDM,402,RC,76700,HCPCS,Outpatient,,,544.85,326.91,,463.12,85,,370.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.17,32.15,,140.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.04,80.03,,348.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,490.37,90,,392.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.17,32.15,,140.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,175.17,32.15,,140.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,479.47,88,,383.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.4,33.11,,144.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.17,490.37,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24010,CDM,402,RC,76705,HCPCS,Outpatient,,,544.85,326.91,,463.12,85,,370.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.17,32.15,,140.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.04,80.03,,348.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,490.37,90,,392.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.17,32.15,,140.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,175.17,32.15,,140.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,479.47,88,,383.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.4,33.11,,144.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.17,490.37,
CUTDOWN VENIPUNCTURE > 1 YO,1436425,CDM,450,RC,36425,HCPCS,Outpatient,,,545.5,327.3,,463.68,85,,370.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.56,80.03,,349.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,490.95,90,,392.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.04,88,,384.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.62,33.11,,144.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.38,490.95,
INTRAOSSEOUS IV,1436680,CDM,450,RC,36680,HCPCS,Outpatient,,,545.5,327.3,,463.68,85,,370.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.56,80.03,,349.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,490.95,90,,392.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.04,88,,384.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.62,33.11,,144.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.38,490.95,
MOUTH LAC < 2.5 CM,1441250,CDM,450,RC,41250,HCPCS,Outpatient,,,545.5,327.3,,463.68,85,,370.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.56,80.03,,349.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,490.95,90,,392.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.04,88,,384.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.62,33.11,,144.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.38,490.95,
REM PHARYNGEAL FOREIGN BODY,1442809,CDM,450,RC,42809,HCPCS,Outpatient,,,545.5,327.3,,463.68,85,,370.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.56,80.03,,349.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,490.95,90,,392.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.04,88,,384.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.62,33.11,,144.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.38,490.95,
"EMBED CONJUNCT, FB REM",1465210,CDM,450,RC,65210,HCPCS,Outpatient,,,545.5,327.3,,463.68,85,,370.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.56,80.03,,349.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,490.95,90,,392.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.04,88,,384.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.62,33.11,,144.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.38,490.95,
GASTRIC LAVAGE,1491105,CDM,450,RC,43752,HCPCS,Outpatient,,,545.5,327.3,,463.68,85,,370.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.56,80.03,,349.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,490.95,90,,392.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,175.38,32.15,,140.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.04,88,,384.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.62,33.11,,144.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.38,490.95,
P/T NON-SELECTIVE DEBRIDEMENT,3971,CDM,420,RC,97602,HCPCS,Outpatient,,,545.94,327.56,,464.05,85,,371.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.92,80.03,,349.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,491.35,90,,393.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.43,88,,384.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.76,33.11,,144.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.52,491.35,
Incision and drainage of abscess; simple or single and complex or multiple,1410060,CDM,450,RC,10060,HCPCS,Outpatient,,,545.94,327.56,,464.05,85,,371.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.92,80.03,,349.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,491.35,90,,393.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.43,88,,384.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.76,33.11,,144.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.52,491.35,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",1412001,CDM,450,RC,12001,HCPCS,Outpatient,,,545.94,327.56,,464.05,85,,371.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.92,80.03,,349.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,491.35,90,,393.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.43,88,,384.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.76,33.11,,144.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.52,491.35,
SIM LAC 2.6-7.5 CM,1412002,CDM,450,RC,12002,HCPCS,Outpatient,,,545.94,327.56,,464.05,85,,371.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.92,80.03,,349.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,491.35,90,,393.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.43,88,,384.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.76,33.11,,144.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.52,491.35,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",1412011,CDM,450,RC,12011,HCPCS,Outpatient,,,545.94,327.56,,464.05,85,,371.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.92,80.03,,349.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,491.35,90,,393.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.43,88,,384.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.76,33.11,,144.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.52,491.35,
NEGATIVE PRESSURE WOUND THERAPY,97605,CDM,761,RC,97605,HCPCS,Outpatient,,,545.94,327.56,,464.05,85,,371.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.92,80.03,,349.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,491.35,90,,393.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,175.52,32.15,,140.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.43,88,,384.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.76,33.11,,144.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.52,491.35,
DRUG SCREEN: SEXUAL ASSAULT  (MAYO),1890000,CDM,300,RC,84999,HCPCS,Outpatient,,,546.75,328.05,,464.74,85,,371.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.78,32.15,,140.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.56,80.03,,350.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,492.08,90,,393.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.78,32.15,,140.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,175.78,32.15,,140.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,481.14,88,,384.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.03,33.11,,144.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.78,492.08,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24051,CDM,402,RC,76705,HCPCS,Outpatient,,,547.75,328.65,,465.59,85,,372.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.1,32.15,,140.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.36,80.03,,350.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,492.98,90,,394.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.1,32.15,,140.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,176.1,32.15,,140.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.02,88,,385.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.36,33.11,,145.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.1,492.98,
(E) US BREAST ECHOGRAPHY,24087,CDM,402,RC,76641,HCPCS,Outpatient,,,547.75,328.65,,465.59,85,,372.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.1,32.15,,140.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.36,80.03,,350.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,492.98,90,,394.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.1,32.15,,140.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,176.1,32.15,,140.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.02,88,,385.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.36,33.11,,145.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.1,492.98,
CATH CYSTOSTOMY COOK 12fr 54cm 083312,49625,CDM,270,RC,,,Outpatient,,,548,328.8,,465.8,85,,372.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.18,32.15,,140.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.56,80.03,,350.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,493.2,90,,394.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.18,32.15,,140.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.18,32.15,,140.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.24,88,,385.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.44,33.11,,145.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.18,493.2,
HIP ARTHRO INJ,22001,CDM,320,RC,73525,HCPCS,Outpatient,,,548,328.8,,465.8,85,,372.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.18,32.15,,140.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.56,80.03,,350.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,493.2,90,,394.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.18,32.15,,140.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,176.18,32.15,,140.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.24,88,,385.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.44,33.11,,145.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.18,493.2,
HEMOSTAT ARISTA 3.0GM BELLOWS,4910082,CDM,270,RC,,,Outpatient,,,548.25,328.95,,466.01,85,,372.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.26,32.15,,141.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.76,80.03,,351.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,493.43,90,,394.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.26,32.15,,141.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.26,32.15,,141.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.46,88,,385.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.53,33.11,,145.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.26,493.43,
O/T DORSAL BLOCKING SPLINT W/O DYNAMICS,3945,CDM,430,RC,L3805,HCPCS,Outpatient,,,548.25,328.95,,466.01,85,,372.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.26,32.15,,141.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,438.76,80.03,,351.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,493.43,90,,394.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.26,32.15,,141.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.26,32.15,,141.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.46,88,,385.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.53,33.11,,145.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.26,493.43,
KIT MANAGEMENT FECAL FLEXISEAL,4980077,CDM,270,RC,,,Outpatient,,,548.75,329.25,,466.44,85,,373.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.42,32.15,,141.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,439.16,80.03,,351.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,493.88,90,,395.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.42,32.15,,141.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.42,32.15,,141.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.9,88,,386.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.69,33.11,,145.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.42,493.88,
NM LEXISCAN 4ML,233156,CDM,636,RC,J2785,HCPCS,Outpatient,,,548.75,329.25,,466.44,85,,373.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,439.16,80.03,,351.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,493.88,90,,395.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,34.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,482.9,88,,386.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,34.76,493.88,
SUBCLAVIAN,1436450,CDM,450,RC,,,Outpatient,,,549.5,329.7,,467.08,85,,373.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.66,32.15,,141.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,439.76,80.03,,351.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,494.55,90,,395.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.66,32.15,,141.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.66,32.15,,141.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.56,88,,386.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.94,33.11,,145.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.66,494.55,
DIURIL (chlorothiazide) : 500MG INJ,293072,CDM,636,RC,J1205,HCPCS,Outpatient,,,549.6,329.76,,467.16,85,,373.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.7,32.15,,141.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,439.84,80.03,,351.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,494.64,90,,395.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.7,32.15,,141.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.7,32.15,,141.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.65,88,,386.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.97,33.11,,145.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.7,494.64,
DIURIL (chlorothiazide) 500MG/18ML SW,293881,CDM,636,RC,J1205,HCPCS,Outpatient,,,549.6,329.76,,467.16,85,,373.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.7,32.15,,141.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,439.84,80.03,,351.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,494.64,90,,395.71,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.7,32.15,,141.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.7,32.15,,141.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.65,88,,386.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,181.97,33.11,,145.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.7,494.64,
FACTOR VIII (antihemophilic-human)500iu,296390,CDM,636,RC,J7190,HCPCS,Outpatient,,,550,330,,467.5,85,,374,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,176.83,32.15,,141.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,440.17,80.03,,352.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1.21,102,,,fee schedule,Pays at 102% of CMS APC rate,495,90,,396,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,176.83,32.15,,141.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1.21,100,,,fee schedule,Pays at 100% of CMS APC rate,176.83,32.15,,141.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484,88,,387.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,182.11,33.11,,145.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,176.83,495,
VIRAL LOAD HIV 1 (MAYO),1883891,CDM,300,RC,87536,HCPCS,Outpatient,,,551.75,331.05,,468.99,85,,375.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,441.57,80.03,,353.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,86.8,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,496.58,90,,397.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.8,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,56.5,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,485.54,88,,388.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,56.5,496.58,
BRIDION (suggammadex) 500mg/5mL SDVL,303081,CDM,250,RC,J3490,HCPCS,Outpatient,,,552.24,331.34,,469.4,85,,375.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,177.55,32.15,,142.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,441.96,80.03,,353.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,497.02,90,,397.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,177.55,32.15,,142.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,177.55,32.15,,142.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,485.97,88,,388.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,182.85,33.11,,146.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,177.55,497.02,
FORCEP RADIAL JAW 3-2.2/160 W/NEEDLE,4988020,CDM,270,RC,,,Outpatient,,,555.25,333.15,,471.96,85,,377.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.51,32.15,,142.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.37,80.03,,355.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,499.73,90,,399.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.51,32.15,,142.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,178.51,32.15,,142.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,488.62,88,,390.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,183.84,33.11,,147.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.51,499.73,
CHIKUNGUNYA RNA QL PCR  (MAYO),1886759,CDM,300,RC,87798,HCPCS,Outpatient,,,555.5,333.3,,472.18,85,,377.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,444.57,80.03,,355.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,499.95,90,,399.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,488.84,88,,391.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,499.95,
CLSD TX SHOULDER DISLOC W/MANIP W/O ANES,1423650,CDM,450,RC,23650,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
TX CLSD ELBOW DISLOC W/O ANEST,1424600,CDM,450,RC,24600,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
CLSD TX NURSEMAID ELBOW W/MANIP,1424640,CDM,450,RC,24640,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
CLSD TX DIP OR PIP DISLOC W/ MANIP,1426770,CDM,450,RC,26770,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
CLSD TX HIP DISLOCATION W/O ANEST,1427250,CDM,450,RC,27250,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
CLSD TX PATELLAR DISLOC W/O ANEST,1427560,CDM,450,RC,27560,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
CLSD TX ANKLE DISLOC W/O ANEST,1427840,CDM,450,RC,27840,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
I & D ABSCESS EYELID,1467700,CDM,450,RC,67700,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,253.77,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.77,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
REMOVE EMBED FB-EYELID,1467938,CDM,450,RC,67938,HCPCS,Outpatient,,,555.75,333.45,,472.39,85,,377.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,444.77,80.03,,355.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,253.77,102,,,fee schedule,Pays at 102% of CMS APC rate,500.18,90,,400.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.77,100,,,fee schedule,Pays at 100% of CMS APC rate,178.67,32.15,,142.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.06,88,,391.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.01,33.11,,147.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,178.67,500.18,
BLEDSOE BRACE 22,31002,CDM,270,RC,L1832,HCPCS,Outpatient,,,556.75,334.05,,473.24,85,,378.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,445.57,80.03,,356.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.08,90,,400.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.94,88,,391.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.34,33.11,,147.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179,501.08,
BLEDSOE BRACE 24,314000,CDM,270,RC,L1832,HCPCS,Outpatient,,,556.75,334.05,,473.24,85,,378.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,445.57,80.03,,356.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.08,90,,400.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.94,88,,391.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.34,33.11,,147.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179,501.08,
BLEDSOE BRACE 26,314001,CDM,274,RC,L1832,HCPCS,Outpatient,,,556.75,334.05,,473.24,85,,378.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,445.57,80.03,,356.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.08,90,,400.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,179,32.15,,143.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.94,88,,391.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.34,33.11,,147.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179,501.08,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24034,CDM,402,RC,76705,HCPCS,Outpatient,,,557.5,334.5,,473.88,85,,379.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,446.17,80.03,,356.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,501.75,90,,401.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490.6,88,,392.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.59,33.11,,147.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179.24,501.75,
PORT US CHEST FOR FLUID,24039,CDM,402,RC,76942,HCPCS,Outpatient,,,557.5,334.5,,473.88,85,,379.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,446.17,80.03,,356.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.75,90,,401.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490.6,88,,392.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.59,33.11,,147.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179.24,501.75,
PORT US CYST ASPIRATION,24040,CDM,402,RC,76942,HCPCS,Outpatient,,,557.5,334.5,,473.88,85,,379.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,446.17,80.03,,356.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.75,90,,401.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490.6,88,,392.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.59,33.11,,147.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179.24,501.75,
Ultrasound of back wall of the abdomen with limited areas viewed,24045,CDM,402,RC,76775,HCPCS,Outpatient,,,557.5,334.5,,473.88,85,,379.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,446.17,80.03,,356.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,501.75,90,,401.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490.6,88,,392.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.59,33.11,,147.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179.24,501.75,
PORT US NEEDLE BX,24048,CDM,402,RC,76942,HCPCS,Outpatient,,,557.5,334.5,,473.88,85,,379.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,446.17,80.03,,356.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.75,90,,401.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490.6,88,,392.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.59,33.11,,147.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179.24,501.75,
Ultrasound of the scrotum,24057,CDM,402,RC,76870,HCPCS,Outpatient,,,557.5,334.5,,473.88,85,,379.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,446.17,80.03,,356.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,501.75,90,,401.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490.6,88,,392.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.59,33.11,,147.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179.24,501.75,
PORT US THORAX AND PLEURA,24058,CDM,402,RC,76604,HCPCS,Outpatient,,,557.5,334.5,,473.88,85,,379.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,446.17,80.03,,356.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,501.75,90,,401.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,179.24,32.15,,143.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,490.6,88,,392.48,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,184.59,33.11,,147.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,179.24,501.75,
RBC ANTIGEN TYPING (EACH),1887812,CDM,300,RC,86905,HCPCS,Outpatient,,,557.75,334.65,,474.09,85,,379.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,446.37,80.03,,357.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,501.98,90,,401.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,4.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.82,88,,392.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,4.81,501.98,
ANTIBODY IDENTIFICATION,2086007,CDM,300,RC,86870,HCPCS,Outpatient,,,557.75,334.65,,474.09,85,,379.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,446.37,80.03,,357.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,501.98,90,,401.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,6.12,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.82,88,,392.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.12,501.98,
IMMUNOHISTO MULTIPLEX STAIN TC,2188338,CDM,310,RC,88344,HCPCS,Outpatient,,,557.75,334.65,,474.09,85,,379.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,446.37,80.03,,357.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,501.98,90,,401.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.82,88,,392.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,99.31,501.98,
Pathology test,2188342,CDM,310,RC,88342,HCPCS,Outpatient,,,557.75,334.65,,474.09,85,,379.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,446.37,80.03,,357.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,501.98,90,,401.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.82,88,,392.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,71.58,501.98,
TUMOR IHC ER/PR/HER2,2188360,CDM,310,RC,88360,HCPCS,Outpatient,,,557.75,334.65,,474.09,85,,379.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,446.37,80.03,,357.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,501.98,90,,401.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,97.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.82,88,,392.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,97.65,501.98,
IF INITIAL ANTIBODY STAIN RENAL (MAYO),2188364,CDM,310,RC,88346,HCPCS,Outpatient,,,557.75,334.65,,474.09,85,,379.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,446.37,80.03,,357.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,501.98,90,,401.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,70.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.82,88,,392.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.06,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,70.93,501.98,
"FLOW CYTO CELL SURFACE, TC",2188371,CDM,311,RC,88184,HCPCS,Outpatient,,,557.75,334.65,,474.09,85,,379.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,446.37,80.03,,357.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,501.98,90,,401.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,46.1,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.82,88,,392.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.48,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,46.1,501.98,
CALRECTICULIIN MUTATION EXON 9 (CSI),2188391,CDM,300,RC,81219,HCPCS,Outpatient,,,560,336,,476,85,,380.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,448.17,80.03,,358.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,124.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,504,90,,403.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,492.8,88,,394.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,136.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,132.54,504,
JAK2 V617F MUTATION (CSI),2188393,CDM,300,RC,81270,HCPCS,Outpatient,,,560,336,,476,85,,380.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,448.17,80.03,,358.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,93.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,504,90,,403.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,492.8,88,,394.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,72,504,
"New patient office of other outpatient visit, typically 60 min",99205,CDM,510,RC,99205,HCPCS,Outpatient,,,561,336.6,,476.85,85,,381.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,180.36,32.15,,144.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,448.97,80.03,,359.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504.9,90,,403.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,180.36,32.15,,144.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,180.36,32.15,,144.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,493.68,88,,394.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,185.75,33.11,,148.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,180.36,504.9,
DEBRIDEMENT SUB Q ADD'L 20 SQ CM OR LESS,8411045,CDM,761,RC,11045,HCPCS,Outpatient,,,567.24,340.34,,482.15,85,,385.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,182.37,32.15,,145.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,453.96,80.03,,363.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.52,90,,408.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,182.37,32.15,,145.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,182.37,32.15,,145.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,499.17,88,,399.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,187.81,33.11,,150.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,182.37,510.52,
STAPLER TA 45-35,4999022,CDM,270,RC,,,Outpatient,,,567.5,340.5,,482.38,85,,385.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,182.45,32.15,,145.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,454.17,80.03,,363.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.75,90,,408.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,182.45,32.15,,145.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,182.45,32.15,,145.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,499.4,88,,399.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,187.9,33.11,,150.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,182.45,510.75,
LYMPHOCYTE PROLIFERATION TO AGS (MAYO),1884814,CDM,300,RC,86353,HCPCS,Outpatient,,,568.25,340.95,,483.01,85,,386.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,454.77,80.03,,363.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,50.01,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,511.43,90,,409.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.01,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,61.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,500.06,88,,400.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.49,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,61.64,511.43,
PITRESSIN (vasopressin) 20UNIT/ML VIAL,293143,CDM,250,RC,,,Outpatient,,,568.97,341.38,,483.62,85,,386.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,182.92,32.15,,146.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,455.35,80.03,,364.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,512.07,90,,409.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,182.92,32.15,,146.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,182.92,32.15,,146.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,500.69,88,,400.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,188.39,33.11,,150.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,182.92,512.07,
I & D OF VULVA OR PERINEAL ABSCESS,1456405,CDM,450,RC,56405,HCPCS,Outpatient,,,570.25,342.15,,484.71,85,,387.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,183.34,32.15,,146.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.37,80.03,,365.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,279.89,102,,,fee schedule,Pays at 102% of CMS APC rate,513.23,90,,410.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,183.34,32.15,,146.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.89,100,,,fee schedule,Pays at 100% of CMS APC rate,183.34,32.15,,146.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,501.82,88,,401.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,188.81,33.11,,151.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,183.34,513.23,
REMOVAL IUD,1458301,CDM,450,RC,58301,HCPCS,Outpatient,,,570.25,342.15,,484.71,85,,387.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,183.34,32.15,,146.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.37,80.03,,365.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,279.89,102,,,fee schedule,Pays at 102% of CMS APC rate,513.23,90,,410.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,183.34,32.15,,146.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.89,100,,,fee schedule,Pays at 100% of CMS APC rate,183.34,32.15,,146.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,501.82,88,,401.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,188.81,33.11,,151.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,183.34,513.23,
ALS EMERGENCY TRANSPORT NO SPEC ALS,530328,CDM,540,RC,A0427,HCPCS,Outpatient,,,570.5,342.3,,484.93,85,,387.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,183.42,32.15,,146.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.57,80.03,,365.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,513.45,90,,410.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,183.42,32.15,,146.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,183.42,32.15,,146.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.04,88,,401.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,188.89,33.11,,151.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,183.42,513.45,
ALS EMERGENCY LEVEL 1 SERVICES,530427,CDM,540,RC,A0427,HCPCS,Outpatient,,,570.5,342.3,,484.93,85,,387.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,183.42,32.15,,146.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,456.57,80.03,,365.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,513.45,90,,410.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,183.42,32.15,,146.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,183.42,32.15,,146.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.04,88,,401.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,188.89,33.11,,151.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,183.42,513.45,
JAK2 V617F MUTATION DETECTION  (MAYO),1883888,CDM,300,RC,81270,HCPCS,Outpatient,,,572.25,343.35,,486.41,85,,389.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,457.97,80.03,,366.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,93.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,515.03,90,,412.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,503.58,88,,402.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,72,515.03,
BUR 4.0 ROUND FLUTED MEDIUM,49731,CDM,270,RC,,,Outpatient,,,572.5,343.5,,486.63,85,,389.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,184.06,32.15,,147.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,458.17,80.03,,366.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.25,90,,412.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,184.06,32.15,,147.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,184.06,32.15,,147.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,503.8,88,,403.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,189.55,33.11,,151.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,184.06,515.25,
BUR 3.0 ROUND FLUTED,49732,CDM,270,RC,,,Outpatient,,,572.5,343.5,,486.63,85,,389.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,184.06,32.15,,147.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,458.17,80.03,,366.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.25,90,,412.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,184.06,32.15,,147.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,184.06,32.15,,147.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,503.8,88,,403.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,189.55,33.11,,151.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,184.06,515.25,
"THROMBOPHILIA SCREEN, INHERITED  (MAYO)",1883913,CDM,300,RC,83891,HCPCS,Outpatient,,,573.75,344.25,,487.69,85,,390.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,184.46,32.15,,147.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,459.17,80.03,,367.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,516.38,90,,413.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,184.46,32.15,,147.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,184.46,32.15,,147.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,504.9,88,,403.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,189.97,33.11,,151.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,184.46,516.38,
HFE GENE ANALYSIS  (MAYO),1883912,CDM,300,RC,81256,HCPCS,Outpatient,,,574,344.4,,487.9,85,,390.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,459.37,80.03,,367.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,66.66,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,516.6,90,,413.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,66.66,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,505.12,88,,404.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,40,516.6,
PORT ESOPHAGUS,22216,CDM,320,RC,74220,HCPCS,Outpatient,,,577.5,346.5,,490.88,85,,392.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.17,80.03,,369.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,519.75,90,,415.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.2,88,,406.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.21,33.11,,152.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.67,519.75,
Ultrasound of the pelvis through vagina,24031,CDM,402,RC,76830,HCPCS,Outpatient,,,577.5,346.5,,490.88,85,,392.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.17,80.03,,369.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,519.75,90,,415.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.2,88,,406.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.21,33.11,,152.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.67,519.75,
Ultrasound of abdomen with all areas scanned,24033,CDM,402,RC,76700,HCPCS,Outpatient,,,577.5,346.5,,490.88,85,,392.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.17,80.03,,369.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,519.75,90,,415.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.2,88,,406.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.21,33.11,,152.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.67,519.75,
Ultrasound of the pelvis through vagina,24099,CDM,402,RC,76830,HCPCS,Outpatient,,,577.5,346.5,,490.88,85,,392.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.17,80.03,,369.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,519.75,90,,415.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.2,88,,406.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.21,33.11,,152.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.67,519.75,
Transvaginal ultrasound of uterus,24106,CDM,402,RC,76817,HCPCS,Outpatient,,,577.5,346.5,,490.88,85,,392.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.17,80.03,,369.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,519.75,90,,415.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,185.67,32.15,,148.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.2,88,,406.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.21,33.11,,152.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.67,519.75,
TROCAR TIP BLUNT 10mm W/SYRINGE,4994072,CDM,270,RC,,,Outpatient,,,577.75,346.65,,491.09,85,,392.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.75,32.15,,148.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.37,80.03,,369.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,519.98,90,,415.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.75,32.15,,148.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,185.75,32.15,,148.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.42,88,,406.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.29,33.11,,153.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.75,519.98,
JAK2 EXON 12 MUTATION DETECTION (MAYO),1884802,CDM,300,RC,0027U,HCPCS,Outpatient,,,577.75,346.65,,491.09,85,,392.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.75,32.15,,148.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.37,80.03,,369.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,124.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,519.98,90,,415.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.75,32.15,,148.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,185.75,32.15,,148.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,508.42,88,,406.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.29,33.11,,153.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.75,519.98,
OR HIP OPERATIVE,22199,CDM,320,RC,73502,HCPCS,Outpatient,,,578.5,347.1,,491.73,85,,393.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.99,32.15,,148.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,462.97,80.03,,370.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,520.65,90,,416.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.99,32.15,,148.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,185.99,32.15,,148.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,509.08,88,,407.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.54,33.11,,153.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,185.99,520.65,
RINGS RETRACTOR 14.1CM X 14.1CM,490164,CDM,270,RC,,,Outpatient,,,578.75,347.25,,491.94,85,,393.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,186.07,32.15,,148.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,463.17,80.03,,370.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520.88,90,,416.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,186.07,32.15,,148.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,186.07,32.15,,148.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,509.3,88,,407.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.62,33.11,,153.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,186.07,520.88,
"EPOGEN *NON DIALYSIS*:40,000UNITS INJ",296494,CDM,636,RC,J0885,HCPCS,Outpatient,,,580,348,,493,85,,394.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,464.17,80.03,,371.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.23,102,,,fee schedule,Pays at 102% of CMS APC rate,522,90,,417.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7.23,100,,,fee schedule,Pays at 100% of CMS APC rate,7.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,510.4,88,,408.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.09,522,
"FACTOR V LEIDEN, R506Q  (MAYO)",1883896,CDM,300,RC,81241,HCPCS,Outpatient,,,585.75,351.45,,497.89,85,,398.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,468.78,80.03,,375.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,74.83,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,527.18,90,,421.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,74.83,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,515.46,88,,412.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,40,527.18,
RETRACTOR ALEXIS O LARGE 9-14cm,4980092,CDM,270,RC,,,Outpatient,,,586.25,351.75,,498.31,85,,398.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,188.48,32.15,,150.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,469.18,80.03,,375.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,527.63,90,,422.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,188.48,32.15,,150.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,188.48,32.15,,150.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,515.9,88,,412.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,194.11,33.11,,155.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,188.48,527.63,
DO NOT USE,322028,CDM,440,RC,92510,HCPCS,Outpatient,,,587.5,352.5,,499.38,85,,399.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,188.88,32.15,,151.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,470.18,80.03,,376.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,528.75,90,,423,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,188.88,32.15,,151.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,188.88,32.15,,151.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,517,88,,413.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,194.52,33.11,,155.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,188.88,528.75,
One sided or limited bilateral study,24021,CDM,921,RC,93971,HCPCS,Outpatient,,,592,355.2,,503.2,85,,402.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,190.33,32.15,,152.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473.78,80.03,,379.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,532.8,90,,426.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,190.33,32.15,,152.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,190.33,32.15,,152.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,520.96,88,,416.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,196.01,33.11,,156.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,190.33,532.8,
S/T BEDSIDE FEES STUDY,3292612,CDM,440,RC,92612,HCPCS,Outpatient,,,592.5,355.5,,503.63,85,,402.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,190.49,32.15,,152.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,474.18,80.03,,379.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,65.48,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,533.25,90,,426.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,190.49,32.15,,152.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.48,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,190.49,32.15,,152.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,521.4,88,,417.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,196.18,33.11,,156.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,190.49,533.25,
CHANGE GASTROSTOMY TUBE,1443760,CDM,450,RC,43760,HCPCS,Outpatient,,,594,356.4,,504.9,85,,403.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,475.38,80.03,,380.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,534.6,90,,427.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,522.72,88,,418.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,196.67,33.11,,157.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,190.97,534.6,
INCISION THROMBOSED HEMORRHOID EXT,1446083,CDM,450,RC,46083,HCPCS,Outpatient,,,594,356.4,,504.9,85,,403.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,475.38,80.03,,380.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,205.98,102,,,fee schedule,Pays at 102% of CMS APC rate,534.6,90,,427.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.98,100,,,fee schedule,Pays at 100% of CMS APC rate,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,522.72,88,,418.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,196.67,33.11,,157.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,190.97,534.6,
PORT IVP WWO KUB,22229,CDM,320,RC,74400,HCPCS,Outpatient,,,594.6,356.76,,505.41,85,,404.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.16,32.15,,152.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,475.86,80.03,,380.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,535.14,90,,428.11,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.16,32.15,,152.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,191.16,32.15,,152.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.25,88,,418.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,196.87,33.11,,157.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.16,535.14,
GAMIMMUNE 6 GRAMS,293432,CDM,636,RC,J1566,HCPCS,Outpatient,,,595,357,,505.75,85,,404.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,476.18,80.03,,380.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,78.09,102,,,fee schedule,Pays at 102% of CMS APC rate,535.5,90,,428.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.09,100,,,fee schedule,Pays at 100% of CMS APC rate,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,523.6,88,,418.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,76.57,535.5,
HYSTEROSALPINGOGRAM,22106,CDM,320,RC,74740,HCPCS,Outpatient,,,596.25,357.75,,506.81,85,,405.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.69,32.15,,153.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.18,80.03,,381.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,536.63,90,,429.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.69,32.15,,153.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,191.69,32.15,,153.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,524.7,88,,419.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.42,33.11,,157.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.69,536.63,
RADIAL KERATOTOMY,9300,CDM,360,RC,,,Outpatient,,,596.5,357.9,,507.03,85,,405.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.38,80.03,,381.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,536.85,90,,429.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,524.92,88,,419.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.5,33.11,,158,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.77,536.85,
Complete ultrasound of the pelvis,24018,CDM,402,RC,76856,HCPCS,Outpatient,,,596.5,357.9,,507.03,85,,405.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.38,80.03,,381.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,536.85,90,,429.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,524.92,88,,419.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.5,33.11,,158,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.77,536.85,
US NEEDLE BX,24027,CDM,402,RC,76942,HCPCS,Outpatient,,,596.5,357.9,,507.03,85,,405.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.38,80.03,,381.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,536.85,90,,429.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,524.92,88,,419.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.5,33.11,,158,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.77,536.85,
US INTRAOP,24134,CDM,402,RC,76998,HCPCS,Outpatient,,,596.5,357.9,,507.03,85,,405.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.38,80.03,,381.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,536.85,90,,429.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,191.77,32.15,,153.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,524.92,88,,419.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.5,33.11,,158,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.77,536.85,
KIT PROCEDURE BIOPSY XRAY ASAP,493247,CDM,270,RC,,,Outpatient,,,597,358.2,,507.45,85,,405.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.94,32.15,,153.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.78,80.03,,382.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,537.3,90,,429.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.94,32.15,,153.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,191.94,32.15,,153.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,525.36,88,,420.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.67,33.11,,158.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.94,537.3,
NM GALLIUM DAY 2 OR 3 (LIMITED AREAS),23060,CDM,341,RC,78805,HCPCS,Outpatient,,,597.75,358.65,,508.09,85,,406.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,192.18,32.15,,153.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,478.38,80.03,,382.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,537.98,90,,430.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,192.18,32.15,,153.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,192.18,32.15,,153.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,526.02,88,,420.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.92,33.11,,158.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,192.18,537.98,
FLOSEAL HEMOSTATIC MATRIX,297529,CDM,250,RC,,,Outpatient,,,598.4,359.04,,508.64,85,,406.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,192.39,32.15,,153.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,478.9,80.03,,383.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,538.56,90,,430.85,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,192.39,32.15,,153.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,598.4,,,,Other,Not Separately reimbursable,192.39,32.15,,153.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,526.59,88,,421.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,198.13,33.11,,158.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,192.39,538.56,
FATTY ACID COMPREHENSIVE  (MAYO),1882544,CDM,300,RC,82542,HCPCS,Outpatient,,,599.25,359.55,,509.36,85,,407.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,479.58,80.03,,383.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.57,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,539.33,90,,431.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.57,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,7.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,527.34,88,,421.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,7.55,539.33,
EXTERNAL NEUROSTIMULATOR,4999942,CDM,278,RC,C1897,HCPCS,Outpatient,,,600,360,,510,85,,408,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,192.9,32.15,,154.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.18,80.03,,384.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,540,90,,432,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,192.9,32.15,,154.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,600,,,,Other,Not Separately reimbursable,192.9,32.15,,154.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528,88,,422.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,198.66,33.11,,158.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,192.9,540,
ARTHROGRAM KNEE RT,22215,CDM,320,RC,73580,HCPCS,Outpatient,,,600,360,,510,85,,408,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,192.9,32.15,,154.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.18,80.03,,384.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,540,90,,432,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,192.9,32.15,,154.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,192.9,32.15,,154.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528,88,,422.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,198.66,33.11,,158.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,192.9,540,
"BICILLIN LA : 1,200,000 INJ",296013,CDM,636,RC,J0561,HCPCS,Outpatient,,,600,360,,510,85,,408,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,480.18,80.03,,384.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,20.56,102,,,fee schedule,Pays at 102% of CMS APC rate,540,90,,432,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,20.56,100,,,fee schedule,Pays at 100% of CMS APC rate,20.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,528,88,,422.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.76,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,20.16,540,
URIGLOW MK II STENT,491161,CDM,270,RC,,,Outpatient,,,600.75,360.45,,510.64,85,,408.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,193.14,32.15,,154.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,480.78,80.03,,384.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,540.68,90,,432.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,193.14,32.15,,154.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,600.75,,,,Other,Not Separately reimbursable,193.14,32.15,,154.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528.66,88,,422.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,198.91,33.11,,159.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,193.14,540.68,
PRADER-WILLI/ANGELMAN SYNDROME  (MAYO),1883894,CDM,300,RC,81331,HCPCS,Outpatient,,,601,360.6,,510.85,85,,408.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,480.98,80.03,,384.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,52.09,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,540.9,90,,432.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,52.09,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,40,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,528.88,88,,423.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.2,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,40,540.9,
GI W SMALL BOWEL,22085,CDM,320,RC,74240,HCPCS,Outpatient,,,601.25,360.75,,511.06,85,,408.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,481.18,80.03,,384.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,541.13,90,,432.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,529.1,88,,423.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.07,33.11,,159.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,193.3,541.13,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",22112,CDM,320,RC,76000,HCPCS,Outpatient,,,601.25,360.75,,511.06,85,,408.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,481.18,80.03,,384.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,541.13,90,,432.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,529.1,88,,423.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.07,33.11,,159.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,193.3,541.13,
FISTULA/ABCESS,22120,CDM,320,RC,76080,HCPCS,Outpatient,,,601.25,360.75,,511.06,85,,408.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,481.18,80.03,,384.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.35,102,,,fee schedule,Pays at 102% of CMS APC rate,541.13,90,,432.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.35,100,,,fee schedule,Pays at 100% of CMS APC rate,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,529.1,88,,423.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.07,33.11,,159.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,193.3,541.13,
MRI of brain stem without dye,27100,CDM,610,RC,70551,HCPCS,Outpatient,,,601.25,360.75,,511.06,85,,408.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,481.18,80.03,,384.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,541.13,90,,432.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,529.1,88,,423.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.07,33.11,,159.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,193.3,541.13,
US DUPLEX UPPER ARTERIAL,24118,CDM,921,RC,93930,HCPCS,Outpatient,,,601.25,360.75,,511.06,85,,408.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,481.18,80.03,,384.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,541.13,90,,432.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,193.3,32.15,,154.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,529.1,88,,423.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.07,33.11,,159.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,193.3,541.13,
CONTINUOUS NEB 1ST 2 HOURS,30131,CDM,410,RC,94640,HCPCS,Outpatient,,,602.81,361.69,,512.39,85,,409.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,193.8,32.15,,155.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.43,80.03,,385.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,542.53,90,,434.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,193.8,32.15,,155.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,193.8,32.15,,155.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,530.47,88,,424.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.59,33.11,,159.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,193.8,542.53,
TRAY THORACOSTOMY W/O BOTTLES,49266,CDM,270,RC,,,Outpatient,,,603.75,362.25,,513.19,85,,410.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.11,32.15,,155.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.18,80.03,,386.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,543.38,90,,434.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.11,32.15,,155.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,194.11,32.15,,155.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.3,88,,425.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.9,33.11,,159.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.11,543.38,
"CUTDOWN, ARTERIAL",1436825,CDM,450,RC,,,Outpatient,,,603.75,362.25,,513.19,85,,410.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.11,32.15,,155.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.18,80.03,,386.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,543.38,90,,434.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.11,32.15,,155.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,194.11,32.15,,155.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.3,88,,425.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,199.9,33.11,,159.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.11,543.38,
ALPHA-GLOBIN GENE ANALYSIS  (MAYO),1882692,CDM,300,RC,81257,HCPCS,Outpatient,,,604.5,362.7,,513.83,85,,411.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,483.78,80.03,,387.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,104.3,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,544.05,90,,435.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.3,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,531.96,88,,425.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,193.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,188,544.05,
Echo without doppler study,3008,CDM,480,RC,93307,HCPCS,Outpatient,,,604.5,362.7,,513.83,85,,411.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.78,80.03,,387.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,544.05,90,,435.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.96,88,,425.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.15,33.11,,160.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.35,544.05,
Echo without doppler study,3011,CDM,480,RC,93307,HCPCS,Outpatient,,,604.5,362.7,,513.83,85,,411.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.78,80.03,,387.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,544.05,90,,435.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.96,88,,425.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.15,33.11,,160.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.35,544.05,
Echo without doppler study,4015,CDM,480,RC,93307,HCPCS,Outpatient,,,604.5,362.7,,513.83,85,,411.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.78,80.03,,387.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,544.05,90,,435.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.96,88,,425.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.15,33.11,,160.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.35,544.05,
Echo without doppler study,4018,CDM,480,RC,93307,HCPCS,Outpatient,,,604.5,362.7,,513.83,85,,411.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.78,80.03,,387.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,544.05,90,,435.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.96,88,,425.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.15,33.11,,160.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.35,544.05,
Echo without doppler study,15008,CDM,480,RC,93307,HCPCS,Outpatient,,,604.5,362.7,,513.83,85,,411.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.78,80.03,,387.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,544.05,90,,435.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.96,88,,425.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.15,33.11,,160.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.35,544.05,
Echo without doppler study,15011,CDM,480,RC,93307,HCPCS,Outpatient,,,604.5,362.7,,513.83,85,,411.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.78,80.03,,387.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,544.05,90,,435.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,194.35,32.15,,155.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.96,88,,425.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.15,33.11,,160.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.35,544.05,
SYMBICORT 80/4.5 INH AEROSOL 60 INHAL,291137,CDM,250,RC,,,Outpatient,,,605,363,,514.25,85,,411.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.51,32.15,,155.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.18,80.03,,387.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,544.5,90,,435.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.51,32.15,,155.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,194.51,32.15,,155.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.4,88,,425.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.32,33.11,,160.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.51,544.5,
I & D ABSCESS COMPLICATED OR MULTIPLE,1410061,CDM,450,RC,10061,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",1410160,CDM,450,RC,10160,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
"DEBRIDEMENT SKIN, PARTIAL THICKNESS",1411040,CDM,450,RC,11042,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
WEDGE EXCISION INGROWN NAIL,1411765,CDM,450,RC,11765,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
"SIM LAC BDY,SCLP,20.1-30.0 CM",1412006,CDM,450,RC,12006,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
SIM LAC 20.1-30.0 CM,1412017,CDM,450,RC,12017,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
"TX SUPERFICIAL WOUND DEHISCIENCE,W/PACKI",1412021,CDM,450,RC,12021,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
LYR CLS SCLP TRNK AXL EXTR < 2.5 CM,1412031,CDM,450,RC,12031,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
"LAC INT BODY,SCALP 2.6-7.5 CM",1412032,CDM,450,RC,12032,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
"INT LAC 7.6-12.5 CM BD,SC",1412034,CDM,450,RC,12034,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 12.6-20.0 CM BD SC,1412035,CDM,450,RC,12035,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
"INT LAC <2.5 CM NECK,HAND,FEET",1412041,CDM,450,RC,12041,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 2.6-7.5 CM,1412042,CDM,450,RC,12042,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 20.1-30.0 CM NHF,1412046,CDM,450,RC,12046,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 2.6-5.0 CM,1412052,CDM,450,RC,12052,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 5.1-7.5 CM,1412053,CDM,450,RC,12053,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 7.6-12.5 CM,1412054,CDM,450,RC,12054,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 12.6-20.0 CM,1412055,CDM,450,RC,12055,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
INT LAC 20.6-30CM F/E,1412056,CDM,450,RC,12056,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
DRESS OR DEBRIDE BURN LARGE 9%,1416030,CDM,450,RC,16030,HCPCS,Outpatient,,,605.5,363.3,,514.68,85,,411.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,484.58,80.03,,387.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,544.95,90,,435.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,194.67,32.15,,155.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,532.84,88,,426.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,200.48,33.11,,160.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,194.67,544.95,
FORCEP POSITRAP NON-RETRACTING 240CM,499041,CDM,270,RC,,,Outpatient,,,607.25,364.35,,516.16,85,,412.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,485.98,80.03,,388.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.53,90,,437.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.38,88,,427.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.06,33.11,,160.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.23,546.53,
BASKET STONE POSITRAP RETRIEVAL HELICAL,499042,CDM,270,RC,,,Outpatient,,,607.25,364.35,,516.16,85,,412.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,485.98,80.03,,388.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.53,90,,437.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.38,88,,427.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.06,33.11,,160.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.23,546.53,
FORCEP HOT BOX OVAL,4988021,CDM,270,RC,,,Outpatient,,,607.25,364.35,,516.16,85,,412.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,485.98,80.03,,388.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.53,90,,437.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.23,32.15,,156.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.38,88,,427.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.06,33.11,,160.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.23,546.53,
PLATELET PHERESIS PRODUCT,2086394,CDM,390,RC,P9034,HCPCS,Outpatient,,,607.6,364.56,,516.46,85,,413.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.34,32.15,,156.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,486.26,80.03,,389.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,340.64,102,,,fee schedule,Pays at 102% of CMS APC rate,546.84,90,,437.47,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.34,32.15,,156.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,340.64,100,,,fee schedule,Pays at 100% of CMS APC rate,195.34,32.15,,156.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.69,88,,427.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.18,33.11,,160.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.34,546.84,
BUR SABRE,49730,CDM,270,RC,,,Outpatient,,,607.75,364.65,,516.59,85,,413.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,486.38,80.03,,389.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.98,90,,437.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.82,88,,427.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.23,33.11,,160.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.39,546.98,
SLEEVE COMPRESSION HIGH THIGH MED,491104,CDM,270,RC,,,Outpatient,,,607.75,364.65,,516.59,85,,413.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,486.38,80.03,,389.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.98,90,,437.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.82,88,,427.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.23,33.11,,160.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.39,546.98,
SLEEVE COMPRESSION LARGE HIGH THIGH,491106,CDM,270,RC,,,Outpatient,,,607.75,364.65,,516.59,85,,413.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,486.38,80.03,,389.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.98,90,,437.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.82,88,,427.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.23,33.11,,160.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.39,546.98,
SET PLEURA-VAC UNDERWATER DRAIN,493010,CDM,270,RC,,,Outpatient,,,607.75,364.65,,516.59,85,,413.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,486.38,80.03,,389.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.98,90,,437.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.39,32.15,,156.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,534.82,88,,427.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.23,33.11,,160.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.39,546.98,
O/T RADIUS/ULNAR FRACTURE BRACE FIT/ADJ,3934,CDM,430,RC,L3805,HCPCS,Outpatient,,,609.5,365.7,,518.08,85,,414.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,195.95,32.15,,156.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,487.78,80.03,,390.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,548.55,90,,438.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,195.95,32.15,,156.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.95,32.15,,156.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,536.36,88,,429.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.81,33.11,,161.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,195.95,548.55,
CLSD TX DISTAL PHALANGEOAL FRACTURE,26775,CDM,450,RC,26775,HCPCS,Outpatient,,,610.75,366.45,,519.14,85,,415.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,196.36,32.15,,157.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,488.78,80.03,,391.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,549.68,90,,439.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,196.36,32.15,,157.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,196.36,32.15,,157.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,537.46,88,,429.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,202.22,33.11,,161.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,196.36,549.68,
ADVAIR 115/21 HFA 12GM,292136,CDM,636,RC,J3535,HCPCS,Outpatient,,,611.9,367.14,,520.12,85,,416.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,196.73,32.15,,157.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.7,80.03,,391.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,550.71,90,,440.57,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,196.73,32.15,,157.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,196.73,32.15,,157.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,538.47,88,,430.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,202.6,33.11,,162.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,196.73,550.71,
CHROMASOME ANALYSIS 15-20 CELLS  (MAYO),1888263,CDM,310,RC,88262,HCPCS,Outpatient,,,613.25,367.95,,521.26,85,,417.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,490.78,80.03,,392.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,127.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,551.93,90,,441.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,539.66,88,,431.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,156.73,551.93,
DIFICID (fidaxomicin) 200MG TAB,304920,CDM,250,RC,,,Outpatient,,,613.76,368.26,,521.7,85,,417.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,197.32,32.15,,157.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,491.19,80.03,,392.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,552.38,90,,441.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,197.32,32.15,,157.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,197.32,32.15,,157.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,540.11,88,,432.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,203.22,33.11,,162.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,197.32,552.38,
BLADE SAW KNEE LONG EXTRA,499655,CDM,272,RC,,,Outpatient,,,615.5,369.3,,523.18,85,,418.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,197.88,32.15,,158.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,492.58,80.03,,394.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,553.95,90,,443.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,197.88,32.15,,158.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,197.88,32.15,,158.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,541.64,88,,433.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,203.79,33.11,,163.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,197.88,553.95,
NON-WEIGHT BEARING RIGID DRESSING,499925,CDM,270,RC,L5450,HCPCS,Outpatient,,,616.75,370.05,,524.24,85,,419.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,198.29,32.15,,158.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,493.59,80.03,,394.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,555.08,90,,444.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,198.29,32.15,,158.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,198.29,32.15,,158.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,542.74,88,,434.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,204.21,33.11,,163.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,198.29,555.08,
IMPLANT ARROW MINISCUS 1.1 X 16MM,49083,CDM,278,RC,L8699,HCPCS,Outpatient,,,617.5,370.5,,524.88,85,,419.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,198.53,32.15,,158.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,494.19,80.03,,395.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,555.75,90,,444.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,198.53,32.15,,158.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,198.53,32.15,,158.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,543.4,88,,434.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,204.45,33.11,,163.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,198.53,555.75,
"X-ray of lower and sacral spine, minimum of 4 views",22042,CDM,320,RC,72110,HCPCS,Outpatient,,,617.5,370.5,,524.88,85,,419.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,198.53,32.15,,158.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,494.19,80.03,,395.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,555.75,90,,444.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,198.53,32.15,,158.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,198.53,32.15,,158.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,543.4,88,,434.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,204.45,33.11,,163.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,198.53,555.75,
CT GUIDANCE CODE,26077,CDM,352,RC,77012,HCPCS,Outpatient,,,618.5,371.1,,525.73,85,,420.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,198.85,32.15,,159.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,494.99,80.03,,395.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,556.65,90,,445.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,198.85,32.15,,159.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,198.85,32.15,,159.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,544.28,88,,435.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,204.79,33.11,,163.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,198.85,556.65,
O/T HUMERAL FRACTURE BRACE,3933,CDM,430,RC,L3980,HCPCS,Outpatient,,,619.5,371.7,,526.58,85,,421.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,199.17,32.15,,159.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,495.79,80.03,,396.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,557.55,90,,446.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,199.17,32.15,,159.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,199.17,32.15,,159.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,545.16,88,,436.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,205.12,33.11,,164.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,199.17,557.55,
HEMOGLOBIN ELECTR. MOLECULAR  (MAYO),1881257,CDM,300,RC,81257,HCPCS,Outpatient,,,620.75,372.45,,527.64,85,,422.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,496.79,80.03,,397.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,104.3,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,558.68,90,,446.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,104.3,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,546.26,88,,437.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,193.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,188,558.68,
ARTHROGRAM KNEE LT,22073,CDM,320,RC,73580,HCPCS,Outpatient,,,621,372.6,,527.85,85,,422.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,199.65,32.15,,159.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,496.99,80.03,,397.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,558.9,90,,447.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,199.65,32.15,,159.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,199.65,32.15,,159.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,546.48,88,,437.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,205.61,33.11,,164.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,199.65,558.9,
ALS EMERGENCY TRANSPORT SPECIALIZED,530330,CDM,540,RC,A0434,HCPCS,Outpatient,,,621.25,372.75,,528.06,85,,422.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,199.73,32.15,,159.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,497.19,80.03,,397.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,559.13,90,,447.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,199.73,32.15,,159.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,199.73,32.15,,159.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,546.7,88,,437.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,205.7,33.11,,164.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,199.73,559.13,
ANESTHESIA 1ST 30 MIN,13005,CDM,370,RC,,,Outpatient,,,623.75,374.25,,530.19,85,,424.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,200.54,32.15,,160.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,499.19,80.03,,399.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,561.38,90,,449.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,200.54,32.15,,160.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,200.54,32.15,,160.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,548.9,88,,439.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,206.52,33.11,,165.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,200.54,561.38,
Test for HIV,1884903,CDM,300,RC,87389,HCPCS,Outpatient,,,625,375,,531.25,85,,425,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,500.19,80.03,,400.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,24.56,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,562.5,90,,450,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.56,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,27.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,550,88,,440,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.12,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.3,562.5,
NM THYROID THERAPY 1131,23037,CDM,341,RC,79000,HCPCS,Outpatient,,,627.5,376.5,,533.38,85,,426.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.19,80.03,,401.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,564.75,90,,451.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,552.2,88,,441.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,207.77,33.11,,166.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,201.74,564.75,
NM THYROID THERAPY 1131 SUBSEQUENT EA DA,23038,CDM,341,RC,79000,HCPCS,Outpatient,,,627.5,376.5,,533.38,85,,426.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.19,80.03,,401.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,564.75,90,,451.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,552.2,88,,441.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,207.77,33.11,,166.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,201.74,564.75,
Ultrasound of fetus with limited views,24075,CDM,402,RC,76815,HCPCS,Outpatient,,,627.5,376.5,,533.38,85,,426.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.19,80.03,,401.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,564.75,90,,451.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,552.2,88,,441.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,207.77,33.11,,166.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,201.74,564.75,
Limited ultrasound of the pelvis,24077,CDM,402,RC,76857,HCPCS,Outpatient,,,627.5,376.5,,533.38,85,,426.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.19,80.03,,401.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,564.75,90,,451.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,552.2,88,,441.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,207.77,33.11,,166.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,201.74,564.75,
Transvaginal ultrasound of uterus,24107,CDM,402,RC,76817,HCPCS,Outpatient,,,627.5,376.5,,533.38,85,,426.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,502.19,80.03,,401.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,564.75,90,,451.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,201.74,32.15,,161.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,552.2,88,,441.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,207.77,33.11,,166.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,201.74,564.75,
VENTILATOR INITIAL,30055,CDM,410,RC,94002,HCPCS,Outpatient,,,630,378,,535.5,85,,428.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,202.55,32.15,,162.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,504.19,80.03,,403.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,533.72,102,,,fee schedule,Pays at 102% of CMS APC rate,567,90,,453.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,202.55,32.15,,162.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,533.72,100,,,fee schedule,Pays at 100% of CMS APC rate,202.55,32.15,,162.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.4,88,,443.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,208.59,33.11,,166.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,202.55,567,
"EPOGEN (EPOETIN)*DIALYSIS-20,000 UNITINJ",293431,CDM,636,RC,Q4081,HCPCS,Outpatient,,,630,378,,535.5,85,,428.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,504.19,80.03,,403.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567,90,,453.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,554.4,88,,443.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.71,567,
Draining or injecting medication into a major joint/bursa without ultrasound,1420610,CDM,450,RC,20610,HCPCS,Outpatient,,,631.25,378.75,,536.56,85,,429.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,505.19,80.03,,404.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,568.13,90,,454.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,555.5,88,,444.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,209.01,33.11,,167.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,202.95,568.13,
INJECT TRIGGER POINT 1-2 MUSCLES,20552,CDM,450,RC,20552,HCPCS,Outpatient,,,633.5,380.1,,538.48,85,,430.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,203.67,32.15,,162.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,506.99,80.03,,405.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,570.15,90,,456.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,203.67,32.15,,162.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,203.67,32.15,,162.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,557.48,88,,445.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,209.75,33.11,,167.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,203.67,570.15,
Draining or injecting medication into a small joint/bursa without ultrasound,4027,CDM,761,RC,20600,HCPCS,Outpatient,,,633.5,380.1,,538.48,85,,430.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,203.67,32.15,,162.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,506.99,80.03,,405.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,570.15,90,,456.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,203.67,32.15,,162.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,203.67,32.15,,162.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,557.48,88,,445.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,209.75,33.11,,167.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,203.67,570.15,
CARIMUNE INFUSION  6GM(OP IVIG INFUSION),293526,CDM,636,RC,J1566,HCPCS,Outpatient,,,636,381.6,,540.6,85,,432.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,508.99,80.03,,407.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,78.09,102,,,fee schedule,Pays at 102% of CMS APC rate,572.4,90,,457.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.09,100,,,fee schedule,Pays at 100% of CMS APC rate,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,559.68,88,,447.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,76.57,572.4,
OUTPATIENT CARDIOVERSION,16016,CDM,480,RC,92961,HCPCS,Outpatient,,,636.5,381.9,,541.03,85,,432.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,204.63,32.15,,163.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,509.39,80.03,,407.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,563.84,102,,,fee schedule,Pays at 102% of CMS APC rate,572.85,90,,458.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,204.63,32.15,,163.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,563.84,100,,,fee schedule,Pays at 100% of CMS APC rate,204.63,32.15,,163.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,560.12,88,,448.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,210.75,33.11,,168.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,204.63,572.85,
NM BONE SCAN AND FLOW STUDY,23009,CDM,341,RC,78315,HCPCS,Outpatient,,,637,382.2,,541.45,85,,433.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,204.8,32.15,,163.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,509.79,80.03,,407.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,573.3,90,,458.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,204.8,32.15,,163.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,204.8,32.15,,163.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,560.56,88,,448.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,210.91,33.11,,168.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,204.8,573.3,
MYCOPLASMA PNEUMO PCR (MAYO),1882700,CDM,300,RC,87581,HCPCS,Outpatient,,,642.75,385.65,,546.34,85,,437.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,514.39,80.03,,411.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,35.79,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,578.48,90,,462.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.79,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,24.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,565.62,88,,452.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.67,578.48,
CPR,1492950,CDM,450,RC,92950,HCPCS,Outpatient,,,643.75,386.25,,547.19,85,,437.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,515.19,80.03,,412.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.48,102,,,fee schedule,Pays at 102% of CMS APC rate,579.38,90,,463.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.48,100,,,fee schedule,Pays at 100% of CMS APC rate,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,566.5,88,,453.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,213.15,33.11,,170.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,206.97,579.38,
Measures how much air is in the lungs after taking a deep breath,3085,CDM,460,RC,94726,HCPCS,Outpatient,,,643.75,386.25,,547.19,85,,437.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,515.19,80.03,,412.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.49,102,,,fee schedule,Pays at 102% of CMS APC rate,579.38,90,,463.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.49,100,,,fee schedule,Pays at 100% of CMS APC rate,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,566.5,88,,453.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,213.15,33.11,,170.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,206.97,579.38,
Test to determine if wheezing is present,30076,CDM,460,RC,94060,HCPCS,Outpatient,,,643.75,386.25,,547.19,85,,437.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,515.19,80.03,,412.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.48,102,,,fee schedule,Pays at 102% of CMS APC rate,579.38,90,,463.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.48,100,,,fee schedule,Pays at 100% of CMS APC rate,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,566.5,88,,453.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,213.15,33.11,,170.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,206.97,579.38,
PULM FUNCT TST OSCILLOMETRY,3094728,CDM,460,RC,94728,HCPCS,Outpatient,,,643.75,386.25,,547.19,85,,437.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,515.19,80.03,,412.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.49,102,,,fee schedule,Pays at 102% of CMS APC rate,579.38,90,,463.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.49,100,,,fee schedule,Pays at 100% of CMS APC rate,206.97,32.15,,165.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,566.5,88,,453.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,213.15,33.11,,170.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,206.97,579.38,
PROBE QUICKSLIVER BIPOLAR COAGULATION,4999059,CDM,270,RC,,,Outpatient,,,647,388.2,,549.95,85,,439.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,208.01,32.15,,166.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,517.79,80.03,,414.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,582.3,90,,465.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,208.01,32.15,,166.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,208.01,32.15,,166.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,569.36,88,,455.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,214.22,33.11,,171.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,208.01,582.3,
VENOGRAM EXTREMITY UNILAT LT,22107,CDM,320,RC,75820,HCPCS,Outpatient,,,647.75,388.65,,550.59,85,,440.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,518.39,80.03,,414.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.41,102,,,fee schedule,Pays at 102% of CMS APC rate,582.98,90,,466.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.41,100,,,fee schedule,Pays at 100% of CMS APC rate,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,570.02,88,,456.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,214.47,33.11,,171.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,208.25,582.98,
VENOGRAM EXTREMITY UNILAT RT,22367,CDM,320,RC,75820,HCPCS,Outpatient,,,647.75,388.65,,550.59,85,,440.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,518.39,80.03,,414.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.41,102,,,fee schedule,Pays at 102% of CMS APC rate,582.98,90,,466.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.41,100,,,fee schedule,Pays at 100% of CMS APC rate,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,570.02,88,,456.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,214.47,33.11,,171.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,208.25,582.98,
EEG (AWAKE & ASLEEP),28010,CDM,740,RC,95819,HCPCS,Outpatient,,,647.75,388.65,,550.59,85,,440.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,518.39,80.03,,414.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.48,102,,,fee schedule,Pays at 102% of CMS APC rate,582.98,90,,466.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.48,100,,,fee schedule,Pays at 100% of CMS APC rate,208.25,32.15,,166.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,570.02,88,,456.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,214.47,33.11,,171.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,208.25,582.98,
ZOVIRAX (acyclovir) 5% CR 5GM,298001,CDM,250,RC,,,Outpatient,,,650,390,,552.5,85,,442,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,520.2,80.03,,416.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,585,90,,468,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,572,88,,457.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,215.22,33.11,,172.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,208.98,585,
GAMUNEX 10% 5GM (BAYER)  INFUSION,293482,CDM,636,RC,J1566,HCPCS,Outpatient,,,650,390,,552.5,85,,442,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,520.2,80.03,,416.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,78.09,102,,,fee schedule,Pays at 102% of CMS APC rate,585,90,,468,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.09,100,,,fee schedule,Pays at 100% of CMS APC rate,76.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,572,88,,457.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.87,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,76.57,585,
NM MAG III,2932281,CDM,636,RC,A9562,HCPCS,Outpatient,,,650,390,,552.5,85,,442,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,520.2,80.03,,416.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,585,90,,468,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,572,88,,457.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,215.22,33.11,,172.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,208.98,585,
KIT URETERAL INFRAVISION,4999024,CDM,270,RC,,,Outpatient,,,651.75,391.05,,553.99,85,,443.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,209.54,32.15,,167.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,521.6,80.03,,417.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,586.58,90,,469.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,209.54,32.15,,167.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,209.54,32.15,,167.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,573.54,88,,458.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,215.79,33.11,,172.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,209.54,586.58,
CT BX SET ACKERMANN ABC-100,26084,CDM,270,RC,,,Outpatient,,,652.25,391.35,,554.41,85,,443.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,209.7,32.15,,167.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,522,80.03,,417.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,587.03,90,,469.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,209.7,32.15,,167.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,209.7,32.15,,167.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,573.98,88,,459.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,215.96,33.11,,172.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,209.7,587.03,
CT BX SET ACKERMANN ABC-200,26085,CDM,270,RC,,,Outpatient,,,652.25,391.35,,554.41,85,,443.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,209.7,32.15,,167.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,522,80.03,,417.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,587.03,90,,469.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,209.7,32.15,,167.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,209.7,32.15,,167.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,573.98,88,,459.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,215.96,33.11,,172.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,209.7,587.03,
ESOPHAGUS,22082,CDM,320,RC,74220,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
BARIUM ENEMA,22087,CDM,320,RC,74270,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
IVP,22098,CDM,320,RC,74400,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CYSTOGRAM NON-VOIDING,22100,CDM,320,RC,74430,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
BARIUM ENEMA DIAGNOSTIC,22378,CDM,320,RC,74270,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
OR CYSTOGRAM NON-VOIDING,22601,CDM,320,RC,74430,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT ORBITS WWO CONTRAST,26006,CDM,351,RC,70482,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT FACIAL BONES W AND WO CONTRAST,26150,CDM,351,RC,70488,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT THORACIC WO CONTRAST,26016,CDM,352,RC,72128,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT EXTREM UP WO CONTRAST LT,26021,CDM,352,RC,73200,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT scan of leg without dye,26024,CDM,352,RC,73700,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT EXTREM LOW W CONTRAST LT,26025,CDM,352,RC,73701,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT scan of leg without dye,26104,CDM,352,RC,73700,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
CT EXTREM UP WO CONTRAST RT,26107,CDM,352,RC,73200,HCPCS,Outpatient,,,654,392.4,,555.9,85,,444.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.4,80.03,,418.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,588.6,90,,470.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,210.26,32.15,,168.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.52,88,,460.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.54,33.11,,173.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.26,588.6,
SLEEVE CALF COMPRESSION MED,491101,CDM,270,RC,,,Outpatient,,,654.69,392.81,,556.49,85,,445.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.48,32.15,,168.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.95,80.03,,419.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.22,90,,471.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.48,32.15,,168.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,210.48,32.15,,168.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,576.13,88,,460.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.77,33.11,,173.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.48,589.22,
SLEEVE CALF COMPRESSION LARGE,491105,CDM,270,RC,,,Outpatient,,,654.69,392.81,,556.49,85,,445.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.48,32.15,,168.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.95,80.03,,419.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.22,90,,471.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.48,32.15,,168.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,210.48,32.15,,168.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,576.13,88,,460.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.77,33.11,,173.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.48,589.22,
Removal of infected skin,1411000,CDM,450,RC,11000,HCPCS,Outpatient,,,656.25,393.75,,557.81,85,,446.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.98,32.15,,168.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,525.2,80.03,,420.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,590.63,90,,472.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.98,32.15,,168.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,210.98,32.15,,168.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,577.5,88,,462,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,217.28,33.11,,173.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.98,590.63,
Complete ultrasound of the pelvis,24043,CDM,402,RC,76856,HCPCS,Outpatient,,,657.25,394.35,,558.66,85,,446.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,211.31,32.15,,169.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,526,80.03,,420.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,591.53,90,,473.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,211.31,32.15,,169.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,211.31,32.15,,169.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,578.38,88,,462.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,217.62,33.11,,174.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,211.31,591.53,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,24050,CDM,402,RC,76805,HCPCS,Outpatient,,,657.25,394.35,,558.66,85,,446.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,211.31,32.15,,169.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,526,80.03,,420.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,591.53,90,,473.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,211.31,32.15,,169.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,211.31,32.15,,169.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,578.38,88,,462.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,217.62,33.11,,174.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,211.31,591.53,
MRI BREAST BIOPSY,27080,CDM,610,RC,77021,HCPCS,Outpatient,,,658.5,395.1,,559.73,85,,447.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,211.71,32.15,,169.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,527,80.03,,421.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,592.65,90,,474.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,211.71,32.15,,169.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,211.71,32.15,,169.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,579.48,88,,463.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,218.03,33.11,,174.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,211.71,592.65,
FACET INJ CERV/THORACIC UNIL,22304,CDM,320,RC,64470,HCPCS,Outpatient,,,660,396,,561,85,,448.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528.2,80.03,,422.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594,90,,475.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,580.8,88,,464.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,218.53,33.11,,174.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.19,594,
FACET INJ CERV/THORACIC EA ADD UNIL,22306,CDM,320,RC,64472,HCPCS,Outpatient,,,660,396,,561,85,,448.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528.2,80.03,,422.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594,90,,475.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,580.8,88,,464.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,218.53,33.11,,174.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.19,594,
FACET INJ LUMB/SACR EA ADD UNIL,22310,CDM,320,RC,64476,HCPCS,Outpatient,,,660,396,,561,85,,448.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528.2,80.03,,422.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594,90,,475.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,580.8,88,,464.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,218.53,33.11,,174.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.19,594,
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,22316,CDM,320,RC,64483,HCPCS,Outpatient,,,660,396,,561,85,,448.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528.2,80.03,,422.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,594,90,,475.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,580.8,88,,464.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,218.53,33.11,,174.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.19,594,
NERVE ROOT BLOCK LUMBAR EA ADD,22317,CDM,320,RC,64484,HCPCS,Outpatient,,,660,396,,561,85,,448.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,528.2,80.03,,422.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594,90,,475.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.19,32.15,,169.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,580.8,88,,464.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,218.53,33.11,,174.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.19,594,
IMPLANT ARROW MINISCUS 1.1 X 10MM,49081,CDM,278,RC,L8699,HCPCS,Outpatient,,,661.5,396.9,,562.28,85,,449.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.67,32.15,,170.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,529.4,80.03,,423.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,595.35,90,,476.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.67,32.15,,170.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.67,32.15,,170.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,582.12,88,,465.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,219.02,33.11,,175.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.67,595.35,
IMPLANT ARROW MINISCUS 1.1 X 13MM,49082,CDM,278,RC,L8699,HCPCS,Outpatient,,,661.5,396.9,,562.28,85,,449.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.67,32.15,,170.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,529.4,80.03,,423.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,595.35,90,,476.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.67,32.15,,170.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.67,32.15,,170.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,582.12,88,,465.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,219.02,33.11,,175.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.67,595.35,
ASCORBIC ACID 500MG/ML INJECTION 50ML,292004,CDM,636,RC,J3490,HCPCS,Outpatient,,,662.4,397.44,,563.04,85,,450.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,212.96,32.15,,170.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,530.12,80.03,,424.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.16,90,,476.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,212.96,32.15,,170.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.96,32.15,,170.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,582.91,88,,466.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,219.32,33.11,,175.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,212.96,596.16,
"PCV, JAK2 V617F, JAK2, EXON 12-15 (MAYO)",1884816,CDM,300,RC,81270,HCPCS,Outpatient,,,670.25,402.15,,569.71,85,,455.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,536.4,80.03,,429.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,93.49,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,603.23,90,,482.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,93.49,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,72,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,589.82,88,,471.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.16,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,72,603.23,
VOYANT 5MM FUSION,4980112,CDM,270,RC,A4649,HCPCS,Outpatient,,,672.75,403.65,,571.84,85,,457.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,538.4,80.03,,430.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,605.48,90,,484.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,592.02,88,,473.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,222.75,33.11,,178.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,216.29,605.48,
VOYANT OPEN FUSION,4980113,CDM,270,RC,A4649,HCPCS,Outpatient,,,672.75,403.65,,571.84,85,,457.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,538.4,80.03,,430.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,605.48,90,,484.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,592.02,88,,473.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,222.75,33.11,,178.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,216.29,605.48,
VOYANT MARYLAND FUSION,4980114,CDM,270,RC,A4649,HCPCS,Outpatient,,,672.75,403.65,,571.84,85,,457.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,538.4,80.03,,430.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,605.48,90,,484.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,216.29,32.15,,173.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,592.02,88,,473.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,222.75,33.11,,178.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,216.29,605.48,
CART ISOLATION W/O LINEN,49003,CDM,270,RC,,,Outpatient,,,673.75,404.25,,572.69,85,,458.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,216.61,32.15,,173.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,539.2,80.03,,431.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,606.38,90,,485.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,216.61,32.15,,173.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,216.61,32.15,,173.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,592.9,88,,474.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,223.08,33.11,,178.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,216.61,606.38,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,9021,CDM,320,RC,62322,HCPCS,Outpatient,,,674.75,404.85,,573.54,85,,458.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,216.93,32.15,,173.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,540,80.03,,432,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,607.28,90,,485.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,216.93,32.15,,173.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,216.93,32.15,,173.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,593.78,88,,475.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,223.41,33.11,,178.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,216.93,607.28,
Ultrasound of back wall of the abdomen with all areas viewed,24104,CDM,402,RC,76770,HCPCS,Outpatient,,,677.5,406.5,,575.88,85,,460.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,217.82,32.15,,174.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,542.2,80.03,,433.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,609.75,90,,487.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,217.82,32.15,,174.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,217.82,32.15,,174.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,596.2,88,,476.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,224.32,33.11,,179.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,217.82,609.75,
REGRANEX (BECAPLERMIN) 0.01% 15GM OINT,297103,CDM,250,RC,,,Outpatient,,,680,408,,578,85,,462.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,218.62,32.15,,174.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,544.2,80.03,,435.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,612,90,,489.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,218.62,32.15,,174.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,218.62,32.15,,174.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,598.4,88,,478.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,225.15,33.11,,180.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,218.62,612,
US BREAST BILATERAL,24102,CDM,402,RC,76641,HCPCS,Outpatient,,,681,408.6,,578.85,85,,463.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,218.94,32.15,,175.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,545,80.03,,436,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,612.9,90,,490.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,218.94,32.15,,175.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,218.94,32.15,,175.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,599.28,88,,479.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,225.48,33.11,,180.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,218.94,612.9,
PARACENTESIS ABDOMEN WITHOUT,22384,CDM,320,RC,49082,HCPCS,Outpatient,,,688.55,413.13,,585.27,85,,468.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,221.37,32.15,,177.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,551.05,80.03,,440.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,791.41,102,,,fee schedule,Pays at 102% of CMS APC rate,619.7,90,,495.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,221.37,32.15,,177.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,791.41,100,,,fee schedule,Pays at 100% of CMS APC rate,221.37,32.15,,177.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,605.92,88,,484.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,227.98,33.11,,182.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,221.37,619.7,
KIT LEAD INTRODUCER,4999951,CDM,278,RC,C1894,HCPCS,Outpatient,,,691.75,415.05,,587.99,85,,470.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,222.4,32.15,,177.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,553.61,80.03,,442.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,622.58,90,,498.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,222.4,32.15,,177.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,222.4,32.15,,177.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,608.74,88,,486.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,229.04,33.11,,183.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,222.4,622.58,
DEBRIDEMENT MUSCLE/FASCIA EADDT'L 20 SQ,8411046,CDM,761,RC,11046,HCPCS,Outpatient,,,691.75,415.05,,587.99,85,,470.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,222.4,32.15,,177.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,553.61,80.03,,442.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,622.58,90,,498.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,222.4,32.15,,177.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,222.4,32.15,,177.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,608.74,88,,486.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,229.04,33.11,,183.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,222.4,622.58,
COAG. CONSULT. (VON WILLEBRAND) MAYO,1885307,CDM,300,RC,85245,HCPCS,Outpatient,,,694,416.4,,589.9,85,,471.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,555.41,80.03,,444.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,624.6,90,,499.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,610.72,88,,488.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.85,624.6,
MM BIOPSY WO PROBE,2219102,CDM,360,RC,19101,HCPCS,Outpatient,,,697.75,418.65,,593.09,85,,474.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,224.33,32.15,,179.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,558.41,80.03,,446.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3295.83,102,,,fee schedule,Pays at 102% of CMS APC rate,627.98,90,,502.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,224.33,32.15,,179.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3295.83,100,,,fee schedule,Pays at 100% of CMS APC rate,224.33,32.15,,179.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,614.02,88,,491.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,231.03,33.11,,184.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,224.33,627.98,
GELPOINT ADVANCED ACCESS PLATFORM,4980101,CDM,270,RC,,,Outpatient,,,698.75,419.25,,593.94,85,,475.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,224.65,32.15,,179.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,559.21,80.03,,447.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,628.88,90,,503.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,224.65,32.15,,179.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,224.65,32.15,,179.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,614.9,88,,491.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,231.36,33.11,,185.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,224.65,628.88,
SYMBICORT 160/4.5 INH AEROSOL 60 INHAL,291136,CDM,250,RC,,,Outpatient,,,699.12,419.47,,594.25,85,,475.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,224.77,32.15,,179.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,559.51,80.03,,447.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,629.21,90,,503.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,224.77,32.15,,179.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,224.77,32.15,,179.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,615.23,88,,492.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,231.48,33.11,,185.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,224.77,629.21,
NM LIMITED AREA BONE,23034,CDM,341,RC,78300,HCPCS,Outpatient,,,699.25,419.55,,594.36,85,,475.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,224.81,32.15,,179.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,559.61,80.03,,447.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,629.33,90,,503.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,224.81,32.15,,179.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,224.81,32.15,,179.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,615.34,88,,492.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,231.52,33.11,,185.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,224.81,629.33,
BiPAP,30299,CDM,410,RC,94660,HCPCS,Outpatient,,,700.49,420.29,,595.42,85,,476.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,225.21,32.15,,180.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,560.6,80.03,,448.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,183.59,102,,,fee schedule,Pays at 102% of CMS APC rate,630.44,90,,504.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,225.21,32.15,,180.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,183.59,100,,,fee schedule,Pays at 100% of CMS APC rate,225.21,32.15,,180.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,616.43,88,,493.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,231.93,33.11,,185.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,225.21,630.44,
BUCCAL SMEAR (MAYO),2188130,CDM,310,RC,88160,HCPCS,Outpatient,,,702.25,421.35,,596.91,85,,477.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,562.01,80.03,,449.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,632.03,90,,505.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,617.98,88,,494.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,46.13,632.03,
ELECTRODE X-TENDED TM LIGASURE,4980094,CDM,270,RC,A4649,HCPCS,Outpatient,,,705.75,423.45,,599.89,85,,479.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,226.9,32.15,,181.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,564.81,80.03,,451.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,635.18,90,,508.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,226.9,32.15,,181.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,226.9,32.15,,181.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,621.06,88,,496.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,233.67,33.11,,186.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,226.9,635.18,
UROVYSION FOR BLADDER CANCER  (MAYO),1888368,CDM,310,RC,88368,HCPCS,Outpatient,,,706.25,423.75,,600.31,85,,480.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,169.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,565.21,80.03,,452.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,635.63,90,,508.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,169.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,169.57,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,621.5,88,,497.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,174.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,169.57,635.63,
NM MECKEL'S SCAN,23005,CDM,341,RC,78290,HCPCS,Outpatient,,,707.25,424.35,,601.16,85,,480.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,227.38,32.15,,181.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,566.01,80.03,,452.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,636.53,90,,509.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,227.38,32.15,,181.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,227.38,32.15,,181.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.38,88,,497.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,234.17,33.11,,187.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,227.38,636.53,
KII BALLOON BLUNT TIP 12 X 100MM,4994073,CDM,270,RC,,,Outpatient,,,710.75,426.45,,604.14,85,,483.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,228.51,32.15,,182.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,568.81,80.03,,455.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,639.68,90,,511.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,228.51,32.15,,182.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,228.51,32.15,,182.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,625.46,88,,500.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,235.33,33.11,,188.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,228.51,639.68,
INITIAL TRANSPORT VENTILATOR PER DAY,30061,CDM,410,RC,94002,HCPCS,Outpatient,,,710.94,426.56,,604.3,85,,483.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,228.57,32.15,,182.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,568.97,80.03,,455.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,533.72,102,,,fee schedule,Pays at 102% of CMS APC rate,639.85,90,,511.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,228.57,32.15,,182.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,533.72,100,,,fee schedule,Pays at 100% of CMS APC rate,228.57,32.15,,182.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,625.63,88,,500.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,235.39,33.11,,188.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,228.57,639.85,
ADVAIR  500/50 DISKUS  *HOSP* #14,292124,CDM,636,RC,J3535,HCPCS,Outpatient,,,712,427.2,,605.2,85,,484.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,228.91,32.15,,183.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,569.81,80.03,,455.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,640.8,90,,512.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,228.91,32.15,,183.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,228.91,32.15,,183.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,626.56,88,,501.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,235.74,33.11,,188.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,228.91,640.8,
PULMICORT INHALER 180 MCG,292089,CDM,250,RC,,,Outpatient,,,714.82,428.89,,607.6,85,,486.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,229.81,32.15,,183.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,572.07,80.03,,457.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,643.34,90,,514.67,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,229.81,32.15,,183.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,229.81,32.15,,183.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,629.04,88,,503.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,236.68,33.11,,189.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,229.81,643.34,
Pedi INTRODUCER,4999929,CDM,278,RC,C1894,HCPCS,Outpatient,,,716,429.6,,608.6,85,,486.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,230.19,32.15,,184.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,573.01,80.03,,458.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,644.4,90,,515.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,230.19,32.15,,184.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,230.19,32.15,,184.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,630.08,88,,504.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,237.07,33.11,,189.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,230.19,644.4,
OR IVP,22144,CDM,320,RC,74400,HCPCS,Outpatient,,,716.5,429.9,,609.03,85,,487.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,230.35,32.15,,184.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,573.41,80.03,,458.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,644.85,90,,515.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,230.35,32.15,,184.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,230.35,32.15,,184.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,630.52,88,,504.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,237.23,33.11,,189.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,230.35,644.85,
IVP W/NEPHRO,22370,CDM,320,RC,74415,HCPCS,Outpatient,,,716.5,429.9,,609.03,85,,487.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,230.35,32.15,,184.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,573.41,80.03,,458.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,644.85,90,,515.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,230.35,32.15,,184.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,230.35,32.15,,184.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,630.52,88,,504.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,237.23,33.11,,189.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,230.35,644.85,
CIPRODEX OTIC SUSPENSION 7.5ML,291047,CDM,250,RC,,,Outpatient,,,717.38,430.43,,609.77,85,,487.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,230.64,32.15,,184.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,574.12,80.03,,459.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,645.64,90,,516.51,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,230.64,32.15,,184.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,230.64,32.15,,184.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,631.29,88,,505.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,237.52,33.11,,190.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,230.64,645.64,
CANNULA ACCUPORT 11GA X 120MM,4999151,CDM,272,RC,,,Outpatient,,,719.25,431.55,,611.36,85,,489.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.62,80.03,,460.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,647.33,90,,517.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,632.94,88,,506.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,238.14,33.11,,190.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,231.24,647.33,
US BREAST LOCALIZATION PLACEMENT 2ND LES,2419286,CDM,320,RC,19286,HCPCS,Outpatient,,,719.25,431.55,,611.36,85,,489.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.62,80.03,,460.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,647.33,90,,517.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,632.94,88,,506.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,238.14,33.11,,190.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,231.24,647.33,
MM BREAST LOCALIZATION PLACEMENT 2ND LES,19286,CDM,403,RC,19286,HCPCS,Outpatient,,,719.25,431.55,,611.36,85,,489.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,575.62,80.03,,460.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,647.33,90,,517.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,231.24,32.15,,184.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,632.94,88,,506.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,238.14,33.11,,190.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,231.24,647.33,
MPL EXON 10 MUTATION (MAYO),1884801,CDM,300,RC,81403,HCPCS,Outpatient,,,721.75,433.05,,613.49,85,,490.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,577.62,80.03,,462.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,188.9,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,649.58,90,,519.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,188.9,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,188,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,635.14,88,,508.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,193.64,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,188,649.58,
TISSUE CULTURE  (I.O),2188239,CDM,300,RC,88239,HCPCS,Outpatient,,,721.75,433.05,,613.49,85,,490.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,185.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,577.62,80.03,,462.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.47,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,649.58,90,,519.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,185.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.47,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,185.51,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,635.14,88,,508.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.08,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,185.51,649.58,
US CHEST WALL,24108,CDM,402,RC,76604,HCPCS,Outpatient,,,726.75,436.05,,617.74,85,,494.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,233.65,32.15,,186.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,581.62,80.03,,465.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,654.08,90,,523.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,233.65,32.15,,186.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,233.65,32.15,,186.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,639.54,88,,511.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,240.63,33.11,,192.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,233.65,654.08,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24133,CDM,402,RC,76705,HCPCS,Outpatient,,,726.75,436.05,,617.74,85,,494.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,233.65,32.15,,186.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,581.62,80.03,,465.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,654.08,90,,523.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,233.65,32.15,,186.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,233.65,32.15,,186.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,639.54,88,,511.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,240.63,33.11,,192.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,233.65,654.08,
ANCHOR SUTURE 3.5MM BIO-PUSHLOCK,4999061,CDM,270,RC,,,Outpatient,,,727.5,436.5,,618.38,85,,494.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,233.89,32.15,,187.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,582.22,80.03,,465.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,654.75,90,,523.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,233.89,32.15,,187.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,233.89,32.15,,187.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,640.2,88,,512.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,240.88,33.11,,192.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,233.89,654.75,
KIT REVISION STERILE,4999934,CDM,270,RC,,,Outpatient,,,732.25,439.35,,622.41,85,,497.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,235.42,32.15,,188.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,586.02,80.03,,468.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,659.03,90,,527.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,235.42,32.15,,188.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,235.42,32.15,,188.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,644.38,88,,515.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,242.45,33.11,,193.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,235.42,659.03,
HUMATROPE (SOMATROPIN) 6MG INJ,295513,CDM,636,RC,J2941,HCPCS,Outpatient,,,733,439.8,,623.05,85,,498.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,586.62,80.03,,469.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.96,102,,,fee schedule,Pays at 102% of CMS APC rate,659.7,90,,527.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,172.96,100,,,fee schedule,Pays at 100% of CMS APC rate,151.81,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,645.04,88,,516.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,156.36,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,151.81,659.7,
CELL SAVER AUTOTRANSFUSION,490050,CDM,300,RC,86891,HCPCS,Outpatient,,,734.75,440.85,,624.54,85,,499.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,236.22,32.15,,188.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,588.02,80.03,,470.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,661.28,90,,529.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,236.22,32.15,,188.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,236.22,32.15,,188.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,646.58,88,,517.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,243.28,33.11,,194.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,236.22,661.28,
(E) US EXT NON-VASCULAR,24080,CDM,402,RC,76881,HCPCS,Outpatient,,,736.75,442.05,,626.24,85,,500.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,236.87,32.15,,189.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,589.62,80.03,,471.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,663.08,90,,530.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,236.87,32.15,,189.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,236.87,32.15,,189.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,648.34,88,,518.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,243.94,33.11,,195.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,236.87,663.08,
One sided or limited bilateral study,24079,CDM,921,RC,93971,HCPCS,Outpatient,,,736.75,442.05,,626.24,85,,500.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,236.87,32.15,,189.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,589.62,80.03,,471.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,663.08,90,,530.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,236.87,32.15,,189.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,236.87,32.15,,189.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,648.34,88,,518.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,243.94,33.11,,195.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,236.87,663.08,
SURGICAL HOOD TOTAL SHIELD,499993,CDM,270,RC,,,Outpatient,,,737.81,442.69,,627.14,85,,501.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,237.21,32.15,,189.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,590.47,80.03,,472.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.03,90,,531.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,237.21,32.15,,189.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,237.21,32.15,,189.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,649.27,88,,519.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,244.29,33.11,,195.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,237.21,664.03,
SET SLEEVE/CABLE 2.0 MM,4999075,CDM,270,RC,L8699,HCPCS,Outpatient,,,738.75,443.25,,627.94,85,,502.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,237.51,32.15,,190.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,591.22,80.03,,472.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.88,90,,531.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,237.51,32.15,,190.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,237.51,32.15,,190.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,650.1,88,,520.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,244.6,33.11,,195.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,237.51,664.88,
NM SCHILLINGS TEST W/IF,23061,CDM,341,RC,78271,HCPCS,Outpatient,,,741,444.6,,629.85,85,,503.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,238.23,32.15,,190.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,593.02,80.03,,474.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.9,90,,533.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,238.23,32.15,,190.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,238.23,32.15,,190.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,652.08,88,,521.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,245.35,33.11,,196.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,238.23,666.9,
NM SCHILLINGS TEST W/OUT IF,23062,CDM,341,RC,78270,HCPCS,Outpatient,,,741,444.6,,629.85,85,,503.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,238.23,32.15,,190.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,593.02,80.03,,474.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.9,90,,533.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,238.23,32.15,,190.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,238.23,32.15,,190.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,652.08,88,,521.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,245.35,33.11,,196.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,238.23,666.9,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",23007,CDM,341,RC,78306,HCPCS,Outpatient,,,741.69,445.01,,630.44,85,,504.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,238.45,32.15,,190.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,593.57,80.03,,474.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,667.52,90,,534.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,238.45,32.15,,190.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,238.45,32.15,,190.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,652.69,88,,522.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,245.57,33.11,,196.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,238.45,667.52,
(E) AMNIOCENTESIS,24086,CDM,402,RC,76946,HCPCS,Outpatient,,,746.25,447.75,,634.31,85,,507.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,239.92,32.15,,191.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,597.22,80.03,,477.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,671.63,90,,537.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,239.92,32.15,,191.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,239.92,32.15,,191.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,656.7,88,,525.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,247.08,33.11,,197.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,239.92,671.63,
TEST STIMULATION KIT,4999936,CDM,278,RC,C1897,HCPCS,Outpatient,,,748.25,448.95,,636.01,85,,508.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,240.56,32.15,,192.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,598.82,80.03,,479.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,673.43,90,,538.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,240.56,32.15,,192.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,240.56,32.15,,192.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,658.46,88,,526.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,247.75,33.11,,198.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,240.56,673.43,
"LARYNGOSCOPY, FLEX FIBEROPTIC W/FB REMOV",1431577,CDM,450,RC,31577,HCPCS,Outpatient,,,749.25,449.55,,636.86,85,,509.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,240.88,32.15,,192.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,599.62,80.03,,479.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.55,102,,,fee schedule,Pays at 102% of CMS APC rate,674.33,90,,539.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,240.88,32.15,,192.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.55,100,,,fee schedule,Pays at 100% of CMS APC rate,240.88,32.15,,192.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,659.34,88,,527.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,248.08,33.11,,198.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,240.88,674.33,
US RENAL ARTERIES,24120,CDM,921,RC,93975,HCPCS,Outpatient,,,751.56,450.94,,638.83,85,,511.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,241.63,32.15,,193.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,601.47,80.03,,481.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,676.4,90,,541.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,241.63,32.15,,193.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,241.63,32.15,,193.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,661.37,88,,529.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,248.84,33.11,,199.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,241.63,676.4,
SULFATIDE AUTOANTIBODY (MAYO),1883043,CDM,300,RC,83520,HCPCS,Outpatient,,,756.25,453.75,,642.81,85,,514.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,605.23,80.03,,484.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,17.61,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,680.63,90,,544.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,17.61,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,665.5,88,,532.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.28,680.63,
ELECTRODE LOOP CUTTING 24FR OVAL WING TI,49079,CDM,270,RC,,,Outpatient,,,756.5,453.9,,643.03,85,,514.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,243.21,32.15,,194.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,605.43,80.03,,484.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,680.85,90,,544.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,243.21,32.15,,194.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,243.21,32.15,,194.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,665.72,88,,532.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,250.48,33.11,,200.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,243.21,680.85,
NEUROMYELITIS OPTICA/AQUAPORIN-4  (MAYO),1884701,CDM,300,RC,86255,HCPCS,Outpatient,,,760.75,456.45,,646.64,85,,517.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,608.83,80.03,,487.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,12.29,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,684.68,90,,547.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.29,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,15.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,669.46,88,,535.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.61,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.16,684.68,
FLOVENT HFA 110MCG INHALER,292079,CDM,250,RC,,,Outpatient,,,765.6,459.36,,650.76,85,,520.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,246.14,32.15,,196.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,612.71,80.03,,490.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,689.04,90,,551.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,246.14,32.15,,196.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,246.14,32.15,,196.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,673.73,88,,538.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,253.49,33.11,,202.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,246.14,689.04,
TRUCLEAR ROTARY MORCELLATOR 4.0,4999946,CDM,272,RC,,,Outpatient,,,766,459.6,,651.1,85,,520.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,246.27,32.15,,197.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,613.03,80.03,,490.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,689.4,90,,551.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,246.27,32.15,,197.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,246.27,32.15,,197.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,674.08,88,,539.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,253.62,33.11,,202.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,246.27,689.4,
US AORTA/IVC GRAFTS,24122,CDM,921,RC,93978,HCPCS,Outpatient,,,766.25,459.75,,651.31,85,,521.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,246.35,32.15,,197.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,613.23,80.03,,490.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,689.63,90,,551.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,246.35,32.15,,197.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,246.35,32.15,,197.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,674.3,88,,539.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,253.71,33.11,,202.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,246.35,689.63,
"EPOGEN (EPOETIN)*DIALYSIS*10,000 UNITINJ",293430,CDM,636,RC,Q4081,HCPCS,Outpatient,,,769.68,461.81,,654.23,85,,523.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,615.97,80.03,,492.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,692.71,90,,554.17,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,769.68,,,,Other,Not Separately reimbursable,0.71,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,677.32,88,,541.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.71,692.71,
IV ADMIN - BIOLOGIC/CHEMO INITIAL HOUR,96413,CDM,335,RC,96413,HCPCS,Outpatient,,,770,462,,654.5,85,,523.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,247.56,32.15,,198.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,616.23,80.03,,492.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,318.87,102,,,fee schedule,Pays at 102% of CMS APC rate,693,90,,554.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,247.56,32.15,,198.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.87,100,,,fee schedule,Pays at 100% of CMS APC rate,247.56,32.15,,198.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.6,88,,542.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,254.95,33.11,,203.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,247.56,693,
PICC DECLOT LINE PROCEDURE,4024,CDM,761,RC,36593,HCPCS,Outpatient,,,770,462,,654.5,85,,523.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,247.56,32.15,,198.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,616.23,80.03,,492.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,318.87,102,,,fee schedule,Pays at 102% of CMS APC rate,693,90,,554.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,247.56,32.15,,198.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.87,100,,,fee schedule,Pays at 100% of CMS APC rate,247.56,32.15,,198.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.6,88,,542.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,254.95,33.11,,203.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,247.56,693,
MAINTENANCE OF WAKEFULLNESS TESTING,30302,CDM,920,RC,95805,HCPCS,Outpatient,,,772,463.2,,656.2,85,,524.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,248.2,32.15,,198.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.83,80.03,,494.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,463.45,102,,,fee schedule,Pays at 102% of CMS APC rate,694.8,90,,555.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,248.2,32.15,,198.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,463.45,100,,,fee schedule,Pays at 100% of CMS APC rate,248.2,32.15,,198.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,679.36,88,,543.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,255.61,33.11,,204.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,248.2,694.8,
Study of vessels on both sides of the head and neck,24001,CDM,921,RC,93880,HCPCS,Outpatient,,,776.13,465.68,,659.71,85,,527.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,249.53,32.15,,199.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,621.14,80.03,,496.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,698.52,90,,558.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,249.53,32.15,,199.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,249.53,32.15,,199.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,682.99,88,,546.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,256.98,33.11,,205.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,249.53,698.52,
Ultrasound of head and neck,24062,CDM,402,RC,76536,HCPCS,Outpatient,,,776.75,466.05,,660.24,85,,528.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,249.73,32.15,,199.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,621.63,80.03,,497.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,699.08,90,,559.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,249.73,32.15,,199.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,249.73,32.15,,199.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,683.54,88,,546.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,257.18,33.11,,205.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,249.73,699.08,
PORT US EXTREMITY VASCULAR,24042,CDM,921,RC,93925,HCPCS,Outpatient,,,776.75,466.05,,660.24,85,,528.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,249.73,32.15,,199.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,621.63,80.03,,497.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,699.08,90,,559.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,249.73,32.15,,199.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,249.73,32.15,,199.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,683.54,88,,546.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,257.18,33.11,,205.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,249.73,699.08,
TRANSFUSION,11007,CDM,391,RC,36430,HCPCS,Outpatient,,,779.25,467.55,,662.36,85,,529.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,250.53,32.15,,200.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,623.63,80.03,,498.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,390.9,102,,,fee schedule,Pays at 102% of CMS APC rate,701.33,90,,561.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,250.53,32.15,,200.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.9,100,,,fee schedule,Pays at 100% of CMS APC rate,250.53,32.15,,200.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,685.74,88,,548.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,258.01,33.11,,206.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,250.53,701.33,
TRANSFUSION,15006,CDM,391,RC,36430,HCPCS,Outpatient,,,779.25,467.55,,662.36,85,,529.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,250.53,32.15,,200.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,623.63,80.03,,498.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,390.9,102,,,fee schedule,Pays at 102% of CMS APC rate,701.33,90,,561.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,250.53,32.15,,200.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.9,100,,,fee schedule,Pays at 100% of CMS APC rate,250.53,32.15,,200.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,685.74,88,,548.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,258.01,33.11,,206.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,250.53,701.33,
GI SERIES,22084,CDM,320,RC,74240,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT scan head or brain without dye,26001,CDM,351,RC,70450,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT ORBITS W CONTRAST,26005,CDM,351,RC,70481,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT FACIAL BONES W CONTRAST,26062,CDM,351,RC,70487,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CTA HEAD,26092,CDM,351,RC,70496,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CTA NECK,26093,CDM,351,RC,70498,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT scan of the thorax without dye,26011,CDM,352,RC,71250,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT CERVICAL W CONTRAST,26015,CDM,352,RC,72126,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT THORACIC W CONTRAST,26017,CDM,352,RC,72129,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT scan of lower spine without dye,26018,CDM,352,RC,72131,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT EXTREM UP W CONTRAST LT,26022,CDM,352,RC,73201,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT of pelvis without dye,26061,CDM,352,RC,72192,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,26094,CDM,352,RC,71275,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CTA ABDOMEN,26098,CDM,352,RC,74175,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CTA ABDOMEN AORTA,26099,CDM,352,RC,75635,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT EXTREM LOW W CONTRAST RT,26103,CDM,352,RC,73701,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CT EXTREM UP W CONTRAST RT,26106,CDM,352,RC,73201,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
CTA ABDOMEN/PELVIS,26125,CDM,352,RC,74174,HCPCS,Outpatient,,,784.5,470.7,,666.83,85,,533.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.84,80.03,,502.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,706.05,90,,564.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,252.22,32.15,,201.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,690.36,88,,552.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,259.75,33.11,,207.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.22,706.05,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24065,CDM,402,RC,76705,HCPCS,Outpatient,,,787.5,472.5,,669.38,85,,535.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,253.18,32.15,,202.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,630.24,80.03,,504.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,708.75,90,,567,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,253.18,32.15,,202.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,253.18,32.15,,202.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,693,88,,554.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,260.74,33.11,,208.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,253.18,708.75,
SLEEP APNEA STUDY,28015,CDM,730,RC,,,Outpatient,,,787.5,472.5,,669.38,85,,535.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,253.18,32.15,,202.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,630.24,80.03,,504.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,708.75,90,,567,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,253.18,32.15,,202.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,787.5,,,,Other,Not Separately reimbursable,253.18,32.15,,202.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,693,88,,554.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,260.74,33.11,,208.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,253.18,708.75,
TRAY THORACOSTOMY REUSEABLE,49267,CDM,270,RC,,,Outpatient,,,789.25,473.55,,670.86,85,,536.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,253.74,32.15,,202.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,631.64,80.03,,505.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,710.33,90,,568.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,253.74,32.15,,202.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,789.25,,,,Other,Not Separately reimbursable,253.74,32.15,,202.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,694.54,88,,555.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,261.32,33.11,,209.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,253.74,710.33,
RETRACTOR ALEXIS O X-LARGE 11-17cm,4980099,CDM,270,RC,,,Outpatient,,,790.94,474.56,,672.3,85,,537.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,254.29,32.15,,203.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,632.99,80.03,,506.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,711.85,90,,569.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,254.29,32.15,,203.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,790.94,,,,Other,Not Separately reimbursable,254.29,32.15,,203.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,696.03,88,,556.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,261.88,33.11,,209.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,254.29,711.85,
TRANSFUSION  BLOOD OR COMPONENT,3005,CDM,391,RC,36430,HCPCS,Outpatient,,,796.02,477.61,,676.62,85,,541.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,255.92,32.15,,204.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,637.05,80.03,,509.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,390.9,102,,,fee schedule,Pays at 102% of CMS APC rate,716.42,90,,573.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,255.92,32.15,,204.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.9,100,,,fee schedule,Pays at 100% of CMS APC rate,255.92,32.15,,204.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,700.5,88,,560.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,263.56,33.11,,210.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,255.92,716.42,
NM MYOCARDIAL IMAGING,2378466,CDM,341,RC,78466,HCPCS,Outpatient,,,797.25,478.35,,677.66,85,,542.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,256.32,32.15,,205.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,638.04,80.03,,510.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,717.53,90,,574.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,256.32,32.15,,205.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,256.32,32.15,,205.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,701.58,88,,561.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,263.97,33.11,,211.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,256.32,717.53,
KIT PREVENA 13CM PEEL N PLACE,49680,CDM,270,RC,,,Outpatient,,,797.5,478.5,,677.88,85,,542.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,256.4,32.15,,205.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,638.24,80.03,,510.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,717.75,90,,574.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,256.4,32.15,,205.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,797.5,,,,Other,Not Separately reimbursable,256.4,32.15,,205.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,701.8,88,,561.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,264.05,33.11,,211.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,256.4,717.75,
KIT PREVENA 20CM PEEL N PLACE,498040,CDM,272,RC,,,Outpatient,,,797.5,478.5,,677.88,85,,542.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,256.4,32.15,,205.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,638.24,80.03,,510.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,717.75,90,,574.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,256.4,32.15,,205.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,797.5,,,,Other,Not Separately reimbursable,256.4,32.15,,205.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,701.8,88,,561.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,264.05,33.11,,211.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,256.4,717.75,
CUBICIN (daptomycin) 350MG VIAL,302495,CDM,636,RC,J0878,HCPCS,Outpatient,,,797.76,478.66,,678.1,85,,542.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,638.45,80.03,,510.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,717.98,90,,574.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,797.76,,,,Other,Not Separately reimbursable,0.04,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,702.03,88,,561.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,0.04,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.04,717.98,
SPECIALTY RESCUE/EXTRACTION,530302,CDM,540,RC,,,Outpatient,,,799.45,479.67,,679.53,85,,543.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,257.02,32.15,,205.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,639.8,80.03,,511.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,719.51,90,,575.61,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,257.02,32.15,,205.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,799.45,,,,Other,Not Separately reimbursable,257.02,32.15,,205.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,703.52,88,,562.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,264.7,33.11,,211.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,257.02,719.51,
NEG PRESSURE WOUND THERAPY VACUUM ASSIST,97607,CDM,360,RC,97607,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
NEG PRESSURE WOUND THPY VACUUM >50 SQ CM,97608,CDM,360,RC,97608,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
I & REM F.B. SIMPLE,1410120,CDM,450,RC,10120,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
REMOVAL OF NAIL BED PERMANENT,1411750,CDM,450,RC,11750,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
SIMPLE LAC 12.6-20.0 CM,1412005,CDM,450,RC,12005,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
CMPLX LAC 1.1-2.5 CM FACE/NECK/HND/FT/AX,1413131,CDM,450,RC,13131,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
BIOPSY OF SKIN,11100,CDM,761,RC,11100,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,804.25,,,,Other,Not Separately reimbursable,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
BIOPSY OF SKIN EA SEPARATE,11101,CDM,761,RC,11101,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,804.25,,,,Other,Not Separately reimbursable,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
EXCISION OF NAIL AND NAIL MATRIX PART/CO,11750,CDM,761,RC,11750,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
ERCP S & I ONLY,22153,CDM,320,RC,74330,HCPCS,Outpatient,,,806.5,483.9,,685.53,85,,548.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,259.29,32.15,,207.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,645.44,80.03,,516.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,725.85,90,,580.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,259.29,32.15,,207.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.5,,,,Other,Not Separately reimbursable,259.29,32.15,,207.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,709.72,88,,567.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,267.03,33.11,,213.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,259.29,725.85,
Ultrasound of back wall of the abdomen with limited areas viewed,24071,CDM,402,RC,76775,HCPCS,Outpatient,,,806.75,484.05,,685.74,85,,548.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,259.37,32.15,,207.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,645.64,80.03,,516.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,726.08,90,,580.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,259.37,32.15,,207.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,259.37,32.15,,207.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,709.94,88,,567.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,267.11,33.11,,213.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,259.37,726.08,
TRANSFUSION,14003,CDM,391,RC,36430,HCPCS,Outpatient,,,807.25,484.35,,686.16,85,,548.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,259.53,32.15,,207.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,646.04,80.03,,516.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,390.9,102,,,fee schedule,Pays at 102% of CMS APC rate,726.53,90,,581.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,259.53,32.15,,207.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.9,100,,,fee schedule,Pays at 100% of CMS APC rate,259.53,32.15,,207.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.38,88,,568.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,267.28,33.11,,213.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,259.53,726.53,
ALS LEVEL 2 SERVICE,530433,CDM,540,RC,A0433,HCPCS,Outpatient,,,810,486,,688.5,85,,550.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,260.42,32.15,,208.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,648.24,80.03,,518.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,729,90,,583.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,260.42,32.15,,208.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,260.42,32.15,,208.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,712.8,88,,570.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,268.19,33.11,,214.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,260.42,729,
CATHETER 2F ARTERIAL EMBOLECTOMY FOGARTY,49590,CDM,272,RC,C1757,HCPCS,Outpatient,,,812,487.2,,690.2,85,,552.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,261.06,32.15,,208.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,649.84,80.03,,519.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,730.8,90,,584.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,261.06,32.15,,208.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,261.06,32.15,,208.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,714.56,88,,571.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,268.85,33.11,,215.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,261.06,730.8,
BILI LIGHTS (DAILY),8070,CDM,270,RC,,,Outpatient,,,817,490.2,,694.45,85,,555.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,262.67,32.15,,210.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,653.85,80.03,,523.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,735.3,90,,588.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,262.67,32.15,,210.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,262.67,32.15,,210.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,718.96,88,,575.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,270.51,33.11,,216.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,262.67,735.3,
RENAL BIOPSY ELECTRON MIC  (MAYO),2188348,CDM,310,RC,88348,HCPCS,Outpatient,,,818.75,491.25,,695.94,85,,556.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,279.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,655.25,80.03,,524.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,736.88,90,,589.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,279.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,279.47,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,720.5,88,,576.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,287.85,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,279.47,736.88,
HEPATITIS C VIRUS GENOTYPING  (MAYO),1887520,CDM,300,RC,87902,HCPCS,Outpatient,,,822.75,493.65,,699.34,85,,559.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,658.45,80.03,,526.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,262.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,740.48,90,,592.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,262.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,109.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,724.02,88,,579.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,109.67,740.48,
CT MAXILLO FACIAL W CONTRAST,26160,CDM,351,RC,70487,HCPCS,Outpatient,,,822.75,493.65,,699.34,85,,559.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,264.51,32.15,,211.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,658.45,80.03,,526.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,740.48,90,,592.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,264.51,32.15,,211.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,264.51,32.15,,211.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,724.02,88,,579.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,272.41,33.11,,217.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,264.51,740.48,
NM MYOCARDIAL STRESS ONLY,23050,CDM,341,RC,78453,HCPCS,Outpatient,,,823.75,494.25,,700.19,85,,560.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,264.84,32.15,,211.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,659.25,80.03,,527.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,741.38,90,,593.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,264.84,32.15,,211.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,264.84,32.15,,211.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,724.9,88,,579.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,272.74,33.11,,218.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,264.84,741.38,
BONE BIOSPY DEEP,22173,CDM,320,RC,20225,HCPCS,Outpatient,,,825,495,,701.25,85,,561,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,265.24,32.15,,212.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,660.25,80.03,,528.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,742.5,90,,594,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,265.24,32.15,,212.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,265.24,32.15,,212.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,726,88,,580.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,273.16,33.11,,218.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,265.24,742.5,
BONE BIOSPY,22319,CDM,320,RC,20220,HCPCS,Outpatient,,,825,495,,701.25,85,,561,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,265.24,32.15,,212.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,660.25,80.03,,528.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,742.5,90,,594,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,265.24,32.15,,212.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,265.24,32.15,,212.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,726,88,,580.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,273.16,33.11,,218.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,265.24,742.5,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24067,CDM,402,RC,76705,HCPCS,Outpatient,,,825.75,495.45,,701.89,85,,561.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,265.48,32.15,,212.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,660.85,80.03,,528.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,743.18,90,,594.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,265.48,32.15,,212.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,265.48,32.15,,212.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,726.66,88,,581.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,273.41,33.11,,218.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,265.48,743.18,
ANCHOR SUTURE 6.5 CROSSFT,4999062,CDM,270,RC,,,Outpatient,,,826.75,496.05,,702.74,85,,562.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,265.8,32.15,,212.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,661.65,80.03,,529.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744.08,90,,595.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,265.8,32.15,,212.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,265.8,32.15,,212.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,727.54,88,,582.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,273.74,33.11,,218.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,265.8,744.08,
CT ORBITS WO CONTRAST,26004,CDM,351,RC,70480,HCPCS,Outpatient,,,829,497.4,,704.65,85,,563.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,663.45,80.03,,530.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,746.1,90,,596.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,729.52,88,,583.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.48,33.11,,219.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,266.52,746.1,
CT TEMPORAL BONE WO CONTRAST,26065,CDM,351,RC,70480,HCPCS,Outpatient,,,829,497.4,,704.65,85,,563.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,663.45,80.03,,530.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,746.1,90,,596.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,729.52,88,,583.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.48,33.11,,219.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,266.52,746.1,
CT Scan of the face and jaw without dye,26071,CDM,351,RC,70486,HCPCS,Outpatient,,,829,497.4,,704.65,85,,563.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,663.45,80.03,,530.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,746.1,90,,596.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,729.52,88,,583.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.48,33.11,,219.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,266.52,746.1,
CT Scan of the face and jaw without dye,26117,CDM,351,RC,70486,HCPCS,Outpatient,,,829,497.4,,704.65,85,,563.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,663.45,80.03,,530.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,746.1,90,,596.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,266.52,32.15,,213.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,729.52,88,,583.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.48,33.11,,219.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,266.52,746.1,
"EPIFIX, PER 1 SQ CM",844131,CDM,636,RC,Q4186,HCPCS,Outpatient,,,830.5,498.3,,705.93,85,,564.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,664.65,80.03,,531.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,747.45,90,,597.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,730.84,88,,584.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.98,33.11,,219.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,267.01,747.45,
"EPIFIX, PER 1 SQ CM",844186,CDM,636,RC,Q4186,HCPCS,Outpatient,,,830.5,498.3,,705.93,85,,564.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,664.65,80.03,,531.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,747.45,90,,597.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,730.84,88,,584.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.98,33.11,,219.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,267.01,747.45,
APPLICATION SKIN SUB GRAFT/ARM/LEG INFAN,15274,CDM,761,RC,15274,HCPCS,Outpatient,,,830.5,498.3,,705.93,85,,564.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,664.65,80.03,,531.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,747.45,90,,597.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,730.84,88,,584.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.98,33.11,,219.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,267.01,747.45,
APPLICATION SKIN SUB GRAFT/FACE/SCALP,15278,CDM,761,RC,15278,HCPCS,Outpatient,,,830.5,498.3,,705.93,85,,564.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,664.65,80.03,,531.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,747.45,90,,597.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,267.01,32.15,,213.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,730.84,88,,584.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,274.98,33.11,,219.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,267.01,747.45,
ANCHOR SUTURE POPLOK 4.5MM,4999063,CDM,270,RC,,,Outpatient,,,833.25,499.95,,708.26,85,,566.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,267.89,32.15,,214.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,666.85,80.03,,533.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.93,90,,599.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,267.89,32.15,,214.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,267.89,32.15,,214.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.26,88,,586.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,275.89,33.11,,220.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,267.89,749.93,
DO NOT USE,322022,CDM,440,RC,92610,HCPCS,Outpatient,,,837,502.2,,711.45,85,,569.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,269.1,32.15,,215.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,669.85,80.03,,535.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,68.87,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,753.3,90,,602.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,269.1,32.15,,215.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.87,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,269.1,32.15,,215.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,736.56,88,,589.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,277.13,33.11,,221.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,269.1,753.3,
ORTHO OTHER ADD 15 MIN,110023,CDM,360,RC,,,Outpatient,,,843.75,506.25,,717.19,85,,573.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,271.27,32.15,,217.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,675.25,80.03,,540.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,759.38,90,,607.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,271.27,32.15,,217.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,271.27,32.15,,217.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,742.5,88,,594,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,279.37,33.11,,223.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,271.27,759.38,
(E) US THORAX AND FLEURA,24063,CDM,402,RC,76604,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24068,CDM,402,RC,76705,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
Ultrasound of back wall of the abdomen with limited areas viewed,24070,CDM,402,RC,76775,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
Ultrasound of back wall of the abdomen with limited areas viewed,24072,CDM,402,RC,76775,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
Ultrasound of the scrotum,24078,CDM,402,RC,76870,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",24082,CDM,402,RC,76882,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
(E) US CYST ASPIRATION,24084,CDM,402,RC,76942,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
(E) US NEEDLE BX,24085,CDM,402,RC,76942,HCPCS,Outpatient,,,846.25,507.75,,719.31,85,,575.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,677.25,80.03,,541.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,761.63,90,,609.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,272.07,32.15,,217.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.7,88,,595.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,280.19,33.11,,224.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.07,761.63,
P/T SETUP CONT PASS MOTION DEVICE,31105,CDM,420,RC,97139,HCPCS,Outpatient,,,850,510,,722.5,85,,578,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,273.28,32.15,,218.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,680.26,80.03,,544.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765,90,,612,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,273.28,32.15,,218.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,273.28,32.15,,218.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,748,88,,598.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,281.44,33.11,,225.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,273.28,765,
NG TUBE INSERTION,14032,CDM,450,RC,43752,HCPCS,Outpatient,,,854,512.4,,725.9,85,,580.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,274.56,32.15,,219.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,683.46,80.03,,546.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,768.6,90,,614.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,274.56,32.15,,219.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,274.56,32.15,,219.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,751.52,88,,601.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,282.76,33.11,,226.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,274.56,768.6,
CORNEAL F.B REMOVAL,1465220,CDM,450,RC,65220,HCPCS,Outpatient,,,854,512.4,,725.9,85,,580.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,274.56,32.15,,219.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,683.46,80.03,,546.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,768.6,90,,614.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,274.56,32.15,,219.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,274.56,32.15,,219.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,751.52,88,,601.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,282.76,33.11,,226.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,274.56,768.6,
STAPLER ENDO GIA 30-2.0 DLU,4999018,CDM,270,RC,,,Outpatient,,,855.75,513.45,,727.39,85,,581.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,275.12,32.15,,220.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,684.86,80.03,,547.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,770.18,90,,616.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,275.12,32.15,,220.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,275.12,32.15,,220.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,753.06,88,,602.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,283.34,33.11,,226.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,275.12,770.18,
SKELETAL SURVEY INFANT,22270,CDM,320,RC,77076,HCPCS,Outpatient,,,856.5,513.9,,728.03,85,,582.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,685.46,80.03,,548.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,770.85,90,,616.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,753.72,88,,602.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,283.59,33.11,,226.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,275.36,770.85,
NM SPLEEN SCAN,23002,CDM,341,RC,78185,HCPCS,Outpatient,,,856.5,513.9,,728.03,85,,582.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,685.46,80.03,,548.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,770.85,90,,616.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,753.72,88,,602.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,283.59,33.11,,226.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,275.36,770.85,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24066,CDM,402,RC,76705,HCPCS,Outpatient,,,856.5,513.9,,728.03,85,,582.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,685.46,80.03,,548.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,770.85,90,,616.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,275.36,32.15,,220.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,753.72,88,,602.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,283.59,33.11,,226.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,275.36,770.85,
Evaluation of speech sound production with evaluation of language comprehension,3292523,CDM,440,RC,92523,HCPCS,Outpatient,,,856.56,513.94,,728.08,85,,582.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,275.38,32.15,,220.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,685.5,80.03,,548.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.02,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,770.9,90,,616.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,275.38,32.15,,220.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.02,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,275.38,32.15,,220.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,753.77,88,,603.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,283.61,33.11,,226.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,275.38,770.9,
Ultrasound of abdomen with all areas scanned,24060,CDM,402,RC,76700,HCPCS,Outpatient,,,866.25,519.75,,736.31,85,,589.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,278.5,32.15,,222.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,693.26,80.03,,554.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,779.63,90,,623.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,278.5,32.15,,222.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,278.5,32.15,,222.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,762.3,88,,609.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,286.82,33.11,,229.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,278.5,779.63,
APP LOW COST SKIN SUB GRAFT ADD 100CM,8415278,CDM,761,RC,15278,HCPCS,Outpatient,,,866.5,519.9,,736.53,85,,589.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,278.58,32.15,,222.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,693.46,80.03,,554.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,779.85,90,,623.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,278.58,32.15,,222.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,278.58,32.15,,222.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,762.52,88,,610.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,286.9,33.11,,229.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,278.58,779.85,
HIP OPERATIVE,22067,CDM,320,RC,73501,HCPCS,Outpatient,,,873.85,524.31,,742.77,85,,594.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,280.94,32.15,,224.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,699.34,80.03,,559.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,786.47,90,,629.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,280.94,32.15,,224.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,280.94,32.15,,224.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,768.99,88,,615.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,289.33,33.11,,231.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,280.94,786.47,
ALEXIS CONTAINED EXTRACTION SYSTEM  14CM,4980102,CDM,270,RC,,,Outpatient,,,879.75,527.85,,747.79,85,,598.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,282.84,32.15,,226.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,704.06,80.03,,563.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,791.78,90,,633.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,282.84,32.15,,226.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,282.84,32.15,,226.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,774.18,88,,619.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,291.29,33.11,,233.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,282.84,791.78,
BED EFICA,49091,CDM,270,RC,,,Outpatient,,,886.25,531.75,,753.31,85,,602.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,284.93,32.15,,227.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,709.27,80.03,,567.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,797.63,90,,638.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,284.93,32.15,,227.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,284.93,32.15,,227.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,779.9,88,,623.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,293.44,33.11,,234.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,284.93,797.63,
INTEGRILIN (EPTIFIBATIDE) 75MG/100ML VIA,292119,CDM,636,RC,J1327,HCPCS,Outpatient,,,895,537,,760.75,85,,608.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,287.74,32.15,,230.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,716.27,80.03,,573.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,805.5,90,,644.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,287.74,32.15,,230.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,287.74,32.15,,230.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,787.6,88,,630.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.33,33.11,,237.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,287.74,805.5,
AGGRASTAT (tirofiban) 12.5MG/250ML PREMX,296103,CDM,636,RC,J3246,HCPCS,Outpatient,,,895,537,,760.75,85,,608.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,287.74,32.15,,230.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,716.27,80.03,,573.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,805.5,90,,644.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,287.74,32.15,,230.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,287.74,32.15,,230.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,787.6,88,,630.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.33,33.11,,237.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,287.74,805.5,
SET THAL-QUICK CHEST TUBE,493699,CDM,270,RC,,,Outpatient,,,895.75,537.45,,761.39,85,,609.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,287.98,32.15,,230.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,716.87,80.03,,573.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.18,90,,644.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,287.98,32.15,,230.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,287.98,32.15,,230.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.26,88,,630.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.58,33.11,,237.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,287.98,806.18,
KIT CATH 40CM DURA-FLOW STRAIGHT BASIC,4980104,CDM,278,RC,C1752,HCPCS,Outpatient,,,896,537.6,,761.6,85,,609.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,717.07,80.03,,573.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.4,90,,645.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.48,88,,630.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.67,33.11,,237.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,288.06,806.4,
KIT CATH 55CM DURA-FLOW STRAIGHT BASIC,4980105,CDM,278,RC,C1788,HCPCS,Outpatient,,,896,537.6,,761.6,85,,609.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,717.07,80.03,,573.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.4,90,,645.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.48,88,,630.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.67,33.11,,237.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,288.06,806.4,
KIT CATH 24CM DURA-FLOW PRE-CURVED,4980106,CDM,278,RC,C1752,HCPCS,Outpatient,,,896,537.6,,761.6,85,,609.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,717.07,80.03,,573.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.4,90,,645.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.48,88,,630.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.67,33.11,,237.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,288.06,806.4,
KIT CATH 28CM DURA-FLOW PRE-CURVED,4980107,CDM,278,RC,C1752,HCPCS,Outpatient,,,896,537.6,,761.6,85,,609.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,717.07,80.03,,573.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.4,90,,645.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.48,88,,630.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.67,33.11,,237.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,288.06,806.4,
KIT CATH 32CM DURA-FLOW STRAIGHT BASIC,4980108,CDM,278,RC,C1752,HCPCS,Outpatient,,,896,537.6,,761.6,85,,609.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,717.07,80.03,,573.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.4,90,,645.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.48,88,,630.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.67,33.11,,237.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,288.06,806.4,
SET CATH 32CM L HEMODIALYSIS 15.5FR,4980128,CDM,278,RC,C1752,HCPCS,Outpatient,,,896,537.6,,761.6,85,,609.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,717.07,80.03,,573.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.4,90,,645.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.48,88,,630.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.67,33.11,,237.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,288.06,806.4,
KIT CATH HEMODIALYSIS 50CM CANNON II PLU,4980129,CDM,278,RC,C1752,HCPCS,Outpatient,,,896,537.6,,761.6,85,,609.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,717.07,80.03,,573.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.4,90,,645.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,288.06,32.15,,230.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,788.48,88,,630.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,296.67,33.11,,237.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,288.06,806.4,
INDIUM 111-OXIDE WBC LABELING KIT,2932299,CDM,636,RC,A9570,HCPCS,Outpatient,,,902.54,541.52,,767.16,85,,613.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,290.17,32.15,,232.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,722.3,80.03,,577.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,812.29,90,,649.83,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,290.17,32.15,,232.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,290.17,32.15,,232.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,794.24,88,,635.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,298.83,33.11,,239.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,290.17,812.29,
NM GASTRIC EMPTYING STUDY,23051,CDM,341,RC,78264,HCPCS,Outpatient,,,904.5,542.7,,768.83,85,,615.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,723.87,80.03,,579.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,814.05,90,,651.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,795.96,88,,636.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,299.48,33.11,,239.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,290.8,814.05,
NM THYROID IMAGING,2378010,CDM,341,RC,78012,HCPCS,Outpatient,,,904.5,542.7,,768.83,85,,615.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,723.87,80.03,,579.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,814.05,90,,651.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,795.96,88,,636.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,299.48,33.11,,239.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,290.8,814.05,
NM PARATHYROID IMAGING,2378070,CDM,341,RC,78070,HCPCS,Outpatient,,,904.5,542.7,,768.83,85,,615.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,723.87,80.03,,579.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,814.05,90,,651.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,290.8,32.15,,232.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,795.96,88,,636.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,299.48,33.11,,239.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,290.8,814.05,
APPLICATION OF UNNA BOOT,2958050,CDM,761,RC,29580,HCPCS,Outpatient,,,914.75,548.85,,777.54,85,,622.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.09,32.15,,235.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,732.07,80.03,,585.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,823.28,90,,658.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.09,32.15,,235.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,294.09,32.15,,235.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,804.98,88,,643.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,302.87,33.11,,242.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.09,823.28,
CT of abdomen without dye,26027,CDM,352,RC,74150,HCPCS,Outpatient,,,916,549.6,,778.6,85,,622.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.07,80.03,,586.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,824.4,90,,659.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.08,88,,644.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.29,33.11,,242.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.49,824.4,
EXPLORATION OF PENETRATING WOUND NECK,1420100,CDM,450,RC,20100,HCPCS,Outpatient,,,916,549.6,,778.6,85,,622.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.07,80.03,,586.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,437.94,102,,,fee schedule,Pays at 102% of CMS APC rate,824.4,90,,659.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.94,100,,,fee schedule,Pays at 100% of CMS APC rate,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.08,88,,644.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.29,33.11,,242.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.49,824.4,
TX MANIDIBULAR FX W/O MANIP,1421450,CDM,450,RC,21450,HCPCS,Outpatient,,,916,549.6,,778.6,85,,622.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.07,80.03,,586.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,437.94,102,,,fee schedule,Pays at 102% of CMS APC rate,824.4,90,,659.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.94,100,,,fee schedule,Pays at 100% of CMS APC rate,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.08,88,,644.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.29,33.11,,242.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.49,824.4,
CRICOTHYROIDOTOMY,1431605,CDM,450,RC,31605,HCPCS,Outpatient,,,916,549.6,,778.6,85,,622.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.07,80.03,,586.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,824.4,90,,659.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.08,88,,644.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.29,33.11,,242.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.49,824.4,
CLSURE LAC VEST > 2.5 CM,1440831,CDM,450,RC,40831,HCPCS,Outpatient,,,916,549.6,,778.6,85,,622.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.07,80.03,,586.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,437.94,102,,,fee schedule,Pays at 102% of CMS APC rate,824.4,90,,659.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.94,100,,,fee schedule,Pays at 100% of CMS APC rate,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.08,88,,644.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.29,33.11,,242.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.49,824.4,
MOUTH LAC > 2.6 CM,1441252,CDM,450,RC,41252,HCPCS,Outpatient,,,916,549.6,,778.6,85,,622.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.07,80.03,,586.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,824.4,90,,659.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,294.49,32.15,,235.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.08,88,,644.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.29,33.11,,242.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.49,824.4,
BIPOLAR SEALER AQM MBS W/LIGHT,491031,CDM,270,RC,,,Outpatient,,,916.61,549.97,,779.12,85,,623.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.69,32.15,,235.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,733.56,80.03,,586.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,824.95,90,,659.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.69,32.15,,235.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,294.69,32.15,,235.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,806.62,88,,645.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.49,33.11,,242.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.69,824.95,
ZASSI BOWEL CATHETER,31130,CDM,270,RC,,,Outpatient,,,918,550.8,,780.3,85,,624.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,295.14,32.15,,236.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,734.68,80.03,,587.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,826.2,90,,660.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,295.14,32.15,,236.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,295.14,32.15,,236.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,807.84,88,,646.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.95,33.11,,243.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,295.14,826.2,
SET CATH 28CM L HEMODIALYSIS 15.5FR,4980125,CDM,278,RC,C1752,HCPCS,Outpatient,,,922.75,553.65,,784.34,85,,627.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,738.48,80.03,,590.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,830.48,90,,664.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,812.02,88,,649.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,305.52,33.11,,244.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,296.66,830.48,
SET CATH 24CM L HEMODIALYSIS 15.5FR,4980126,CDM,278,RC,C1752,HCPCS,Outpatient,,,922.75,553.65,,784.34,85,,627.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,738.48,80.03,,590.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,830.48,90,,664.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,812.02,88,,649.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,305.52,33.11,,244.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,296.66,830.48,
SET CATH HEMODIALYSIS 19CM NEXTSTEP,4980127,CDM,278,RC,C1752,HCPCS,Outpatient,,,922.75,553.65,,784.34,85,,627.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,738.48,80.03,,590.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,830.48,90,,664.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,296.66,32.15,,237.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,812.02,88,,649.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,305.52,33.11,,244.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,296.66,830.48,
GASTRIC INTUBATION,1443753,CDM,450,RC,43753,HCPCS,Outpatient,,,925,555,,786.25,85,,629,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,297.39,32.15,,237.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,740.28,80.03,,592.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.49,102,,,fee schedule,Pays at 102% of CMS APC rate,832.5,90,,666,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,297.39,32.15,,237.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.49,100,,,fee schedule,Pays at 100% of CMS APC rate,297.39,32.15,,237.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,814,88,,651.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,306.27,33.11,,245.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,297.39,832.5,
"GASTRIC INTUBATION AND ASPIRATION, DIAGN",1443754,CDM,450,RC,43754,HCPCS,Outpatient,,,925,555,,786.25,85,,629,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,297.39,32.15,,237.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,740.28,80.03,,592.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.49,102,,,fee schedule,Pays at 102% of CMS APC rate,832.5,90,,666,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,297.39,32.15,,237.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.49,100,,,fee schedule,Pays at 100% of CMS APC rate,297.39,32.15,,237.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,814,88,,651.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,306.27,33.11,,245.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,297.39,832.5,
VON WILLEBRAND PROFILE  (MAYO),1885245,CDM,300,RC,85246,HCPCS,Outpatient,,,927.88,556.73,,788.7,85,,630.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,742.58,80.03,,594.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.39,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,835.09,90,,668.07,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.39,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,28.85,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,816.53,88,,653.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.72,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,28.85,835.09,
EMERGENCY UNSCHEDULED HEMODIALYSIS,17003,CDM,880,RC,G0257,HCPCS,Outpatient,,,928.5,557.1,,789.23,85,,631.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,298.51,32.15,,238.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,743.08,80.03,,594.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,604.48,102,,,fee schedule,Pays at 102% of CMS APC rate,835.65,90,,668.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,298.51,32.15,,238.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,604.48,100,,,fee schedule,Pays at 100% of CMS APC rate,298.51,32.15,,238.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,817.08,88,,653.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,307.43,33.11,,245.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,298.51,835.65,
MESH PELVICOL TISSUE 2X7,4999032,CDM,278,RC,C1713,HCPCS,Outpatient,,,928.75,557.25,,789.44,85,,631.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,298.59,32.15,,238.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,743.28,80.03,,594.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,835.88,90,,668.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,298.59,32.15,,238.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,298.59,32.15,,238.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,817.3,88,,653.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,307.51,33.11,,246.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,298.59,835.88,
REPLACEMENT G TUBE PERCUTANEOUS,1443762,CDM,450,RC,43762,HCPCS,Outpatient,,,930,558,,790.5,85,,632.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,299,32.15,,239.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.28,80.03,,595.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,205.98,102,,,fee schedule,Pays at 102% of CMS APC rate,837,90,,669.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,299,32.15,,239.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.98,100,,,fee schedule,Pays at 100% of CMS APC rate,299,32.15,,239.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,818.4,88,,654.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,307.92,33.11,,246.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,299,837,
OR IMAGE INTENSIFER > 1 HR,22111,CDM,320,RC,76001,HCPCS,Outpatient,,,936,561.6,,795.6,85,,636.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,749.08,80.03,,599.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,842.4,90,,673.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,823.68,88,,658.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,309.91,33.11,,247.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,300.92,842.4,
PACEMAKER DAILY CHARGE,16020,CDM,732,RC,93012,HCPCS,Outpatient,,,936,561.6,,795.6,85,,636.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,749.08,80.03,,599.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,842.4,90,,673.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,823.68,88,,658.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,309.91,33.11,,247.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,300.92,842.4,
ARTERIAL LINE (DAILY),16025,CDM,732,RC,93012,HCPCS,Outpatient,,,936,561.6,,795.6,85,,636.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,749.08,80.03,,599.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,842.4,90,,673.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,823.68,88,,658.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,309.91,33.11,,247.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,300.92,842.4,
Study of vessels on both sides of the head and neck,24061,CDM,921,RC,93880,HCPCS,Outpatient,,,936,561.6,,795.6,85,,636.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,749.08,80.03,,599.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,842.4,90,,673.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,300.92,32.15,,240.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,823.68,88,,658.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,309.91,33.11,,247.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,300.92,842.4,
EACH ADDITIONAL 15 MIN. O.R. CHARGE,9010,CDM,360,RC,,,Outpatient,,,937.19,562.31,,796.61,85,,637.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.31,32.15,,241.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.03,80.03,,600.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,843.47,90,,674.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.31,32.15,,241.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,301.31,32.15,,241.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,824.73,88,,659.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.3,33.11,,248.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.31,843.47,
REPAIR OF NAIL BED SIMPLE,1411760,CDM,450,RC,11760,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
"TX SUPERFICIAL WOUND DEHISCIENCE,SIMPLEC",1412020,CDM,450,RC,12020,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
INT LAC 20.1-30CM BD SC,1412036,CDM,450,RC,12036,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
INT LAC 7.6-12.5 CM,1412044,CDM,450,RC,12044,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
INT LAC 12.6-20.0 CM,1412045,CDM,450,RC,12045,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
CMPLX LAC 1.1-2.5 CM TRUNK,1413100,CDM,450,RC,13100,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
CMPLX LAC 2.6-7.5 CM TRK,1413101,CDM,450,RC,13101,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
"CMPLX LAC 1.1-2.5 CM SCALP,ARMS,LEGS",1413120,CDM,450,RC,13120,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
"CMPLX LAC 2.6-7.5 CM SCLP,ARMS,LEGS",1413121,CDM,450,RC,13121,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
"CMPLX LAC 2.6-7.5 CM FACE,H.F",1413132,CDM,450,RC,13132,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
"CMPLX LAC <1.1 CM NOSE,EARS,EYES,LIPS",1413150,CDM,450,RC,13151,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
"CMPLX LAC 1.0-2.5CM  N,E,E,L",1413151,CDM,450,RC,13151,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
"CMPLX LAC 2.6-7.5 CM N,E,E,L",1413152,CDM,450,RC,13152,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
PINCH GRAFT UP TO 2 CM DIAMETER,1415050,CDM,450,RC,15050,HCPCS,Outpatient,,,937.75,562.65,,797.09,85,,637.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,750.48,80.03,,600.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,843.98,90,,675.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,301.49,32.15,,241.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,825.22,88,,660.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.49,33.11,,248.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.49,843.98,
TRUCLEAR INCISOR DEVICE,4999944,CDM,272,RC,,,Outpatient,,,940.75,564.45,,799.64,85,,639.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,302.45,32.15,,241.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,752.88,80.03,,602.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,846.68,90,,677.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,302.45,32.15,,241.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,302.45,32.15,,241.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,827.86,88,,662.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,311.48,33.11,,249.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,302.45,846.68,
CHROMOSOME ANAL AMNIO FL  (MAYO),1888267,CDM,310,RC,88267,HCPCS,Outpatient,,,944.75,566.85,,803.04,85,,642.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,226.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,756.08,80.03,,604.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,192.34,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,850.28,90,,680.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,226.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,192.34,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,226.05,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,831.38,88,,665.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,232.83,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,226.05,850.28,
Ultrasound of back wall of the abdomen with all areas viewed,24103,CDM,402,RC,76770,HCPCS,Outpatient,,,946.5,567.9,,804.53,85,,643.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,304.3,32.15,,243.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,757.48,80.03,,605.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,851.85,90,,681.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,304.3,32.15,,243.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,304.3,32.15,,243.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,832.92,88,,666.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,313.39,33.11,,250.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,304.3,851.85,
ALS LEVEL 2  STEMI,530435,CDM,540,RC,A0433,HCPCS,Outpatient,,,947.5,568.5,,805.38,85,,644.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,304.62,32.15,,243.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,758.28,80.03,,606.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.75,90,,682.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,304.62,32.15,,243.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,304.62,32.15,,243.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,833.8,88,,667.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,313.72,33.11,,250.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,304.62,852.75,
CT Scan of the face and jaw without dye,26007,CDM,351,RC,70486,HCPCS,Outpatient,,,948,568.8,,805.8,85,,644.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,758.68,80.03,,606.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,853.2,90,,682.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,834.24,88,,667.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,313.88,33.11,,251.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,304.78,853.2,
CT SOFT TISS NECK WO CONTRAST,26009,CDM,351,RC,70490,HCPCS,Outpatient,,,948,568.8,,805.8,85,,644.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,758.68,80.03,,606.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,853.2,90,,682.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,834.24,88,,667.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,313.88,33.11,,251.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,304.78,853.2,
CT of abdomen with dye,26028,CDM,352,RC,74160,HCPCS,Outpatient,,,948,568.8,,805.8,85,,644.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,758.68,80.03,,606.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,853.2,90,,682.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,304.78,32.15,,243.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,834.24,88,,667.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,313.88,33.11,,251.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,304.78,853.2,
Ultrasound of back wall of the abdomen with all areas viewed,24069,CDM,402,RC,76770,HCPCS,Outpatient,,,956,573.6,,812.6,85,,650.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,765.09,80.03,,612.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,860.4,90,,688.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,841.28,88,,673.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,316.53,33.11,,253.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,307.35,860.4,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,24074,CDM,402,RC,76805,HCPCS,Outpatient,,,956,573.6,,812.6,85,,650.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,765.09,80.03,,612.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,860.4,90,,688.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,841.28,88,,673.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,316.53,33.11,,253.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,307.35,860.4,
Complete ultrasound of the pelvis,24076,CDM,402,RC,76856,HCPCS,Outpatient,,,956,573.6,,812.6,85,,650.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,765.09,80.03,,612.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,860.4,90,,688.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,307.35,32.15,,245.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,841.28,88,,673.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,316.53,33.11,,253.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,307.35,860.4,
NEUPOGEN (filgrastim) 300 MCG INJ,293253,CDM,636,RC,J1442,HCPCS,Outpatient,,,961.06,576.64,,816.9,85,,653.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,769.14,80.03,,615.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1,102,,,fee schedule,Pays at 102% of CMS APC rate,864.95,90,,691.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1,100,,,fee schedule,Pays at 100% of CMS APC rate,0.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,845.73,88,,676.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.99,864.95,
MRA HEAD WITHOUT CONTRAST,22348,CDM,320,RC,70544,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI ORBIT WO CONTRAST,27002,CDM,610,RC,70540,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of abdomen without dye,27018,CDM,610,RC,74181,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of pelvis without dye,27021,CDM,610,RC,72195,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRA CAROTID WITHOUT CONTRAST,27043,CDM,610,RC,70547,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI EXT UP NON-JNT WO CONTRAST LT,27065,CDM,610,RC,73218,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI EXT UP NON-JNT WO CONTRAST RT,27066,CDM,610,RC,73218,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI TMJ WITH OR WITHOUT,27089,CDM,610,RC,70336,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of leg without dye,27037,CDM,614,RC,73718,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of leg without dye,27061,CDM,614,RC,73718,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of leg without dye,27618,CDM,614,RC,73718,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of lower extremity joint (knee/ankle) without dye,27621,CDM,614,RC,73721,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of leg without dye,27718,CDM,614,RC,73718,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
MRI of lower extremity joint (knee/ankle) without dye,27721,CDM,614,RC,73721,HCPCS,Outpatient,,,961.5,576.9,,817.28,85,,653.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,769.49,80.03,,615.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,865.35,90,,692.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,309.12,32.15,,247.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,846.12,88,,676.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,318.35,33.11,,254.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,309.12,865.35,
PKD INTERPRETATION   (MAYO),1882050,CDM,300,RC,81479,HCPCS,Outpatient,,,962.5,577.5,,818.13,85,,654.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,890.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,770.29,80.03,,616.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,866.25,90,,693,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,890.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,890.08,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,847,88,,677.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,916.78,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,770.29,890.08,
MPN CALR WITH REFLEX TO MPL (MAYO),1884815,CDM,300,RC,81219,HCPCS,Outpatient,,,965.25,579.15,,820.46,85,,656.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,772.49,80.03,,617.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,124.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,868.73,90,,694.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,849.42,88,,679.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,136.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,132.54,868.73,
(E) KIDNEY IMAGING STATIC ONLY,23025,CDM,341,RC,78700,HCPCS,Outpatient,,,965.5,579.3,,820.68,85,,656.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,310.41,32.15,,248.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,772.69,80.03,,618.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,868.95,90,,695.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,310.41,32.15,,248.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,310.41,32.15,,248.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,849.64,88,,679.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,319.68,33.11,,255.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,310.41,868.95,
EPIFIX 18.0 MM 2.5 SQ CM,49790,CDM,270,RC,,,Outpatient,,,967.75,580.65,,822.59,85,,658.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,311.13,32.15,,248.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,774.49,80.03,,619.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,870.98,90,,696.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,311.13,32.15,,248.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,311.13,32.15,,248.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,851.62,88,,681.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,320.42,33.11,,256.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,311.13,870.98,
CART CRASH,49001,CDM,270,RC,,,Outpatient,,,969.25,581.55,,823.86,85,,659.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,311.61,32.15,,249.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,775.69,80.03,,620.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,872.33,90,,697.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,311.61,32.15,,249.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,311.61,32.15,,249.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,852.94,88,,682.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,320.92,33.11,,256.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,311.61,872.33,
TRANSFUSION,4005,CDM,391,RC,36430,HCPCS,Outpatient,,,970.75,582.45,,825.14,85,,660.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,312.1,32.15,,249.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,776.89,80.03,,621.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,390.9,102,,,fee schedule,Pays at 102% of CMS APC rate,873.68,90,,698.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,312.1,32.15,,249.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.9,100,,,fee schedule,Pays at 100% of CMS APC rate,312.1,32.15,,249.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,854.26,88,,683.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,321.42,33.11,,257.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,312.1,873.68,
LEVEL 2 AIRWAY ENDOSCOPY,9210,CDM,790,RC,,,Outpatient,,,971.75,583.05,,825.99,85,,660.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,312.42,32.15,,249.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,777.69,80.03,,622.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,874.58,90,,699.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,312.42,32.15,,249.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,312.42,32.15,,249.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,855.14,88,,684.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,321.75,33.11,,257.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,312.42,874.58,
REPOSITION CENTRAL VENOUS CATH,36597,CDM,360,RC,36597,HCPCS,Outpatient,,,978,586.8,,831.3,85,,665.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,314.43,32.15,,251.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,782.69,80.03,,626.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,880.2,90,,704.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,314.43,32.15,,251.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,314.43,32.15,,251.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,860.64,88,,688.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,323.82,33.11,,259.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,314.43,880.2,
"CHROMOSOME ANALYSIS, AUTOPSY  (MAYO)",1888260,CDM,310,RC,88262,HCPCS,Outpatient,,,979,587.4,,832.15,85,,665.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,783.49,80.03,,626.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,127.99,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,881.1,90,,704.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,127.99,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,861.52,88,,689.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,156.73,881.1,
LEVEL 2 SKIN PROCEDURE,9275,CDM,790,RC,,,Outpatient,,,983.25,589.95,,835.76,85,,668.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,316.11,32.15,,252.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,786.89,80.03,,629.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,884.93,90,,707.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,316.11,32.15,,252.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,316.11,32.15,,252.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,865.26,88,,692.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,325.55,33.11,,260.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,316.11,884.93,
Injection into lower back of nerve block using imaging guidance,22308,CDM,320,RC,64493,HCPCS,Outpatient,,,983.5,590.1,,835.98,85,,668.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,316.2,32.15,,252.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,787.1,80.03,,629.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,885.15,90,,708.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,316.2,32.15,,252.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,316.2,32.15,,252.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,865.48,88,,692.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,325.64,33.11,,260.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,316.2,885.15,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,22556,CDM,320,RC,62322,HCPCS,Outpatient,,,983.5,590.1,,835.98,85,,668.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,316.2,32.15,,252.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,787.1,80.03,,629.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,885.15,90,,708.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,316.2,32.15,,252.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,316.2,32.15,,252.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,865.48,88,,692.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,325.64,33.11,,260.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,316.2,885.15,
PACEMAKER W/FLUORO,22026,CDM,320,RC,71090,HCPCS,Outpatient,,,988,592.8,,839.8,85,,671.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,317.64,32.15,,254.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,790.7,80.03,,632.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,889.2,90,,711.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,317.64,32.15,,254.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,988,,,,Other,Not Separately reimbursable,317.64,32.15,,254.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,869.44,88,,695.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,327.13,33.11,,261.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,317.64,889.2,
OR PACEMAKER W/FLUORO,22119,CDM,320,RC,71090,HCPCS,Outpatient,,,988,592.8,,839.8,85,,671.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,317.64,32.15,,254.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,790.7,80.03,,632.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,889.2,90,,711.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,317.64,32.15,,254.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,988,,,,Other,Not Separately reimbursable,317.64,32.15,,254.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,869.44,88,,695.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,327.13,33.11,,261.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,317.64,889.2,
EXPAREL(liposomal bupivacaine) 1.3% 20ml,292011,CDM,250,RC,C9290,HCPCS,Outpatient,,,991.3,594.78,,842.61,85,,674.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,318.7,32.15,,254.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,793.34,80.03,,634.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.17,90,,713.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,318.7,32.15,,254.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,991.3,,,,Other,Not Separately reimbursable,318.7,32.15,,254.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,872.34,88,,697.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,328.22,33.11,,262.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,318.7,892.17,
ACETADOTE 200MG/ML 30 ML VIAL (6G),293536,CDM,250,RC,,,Outpatient,,,993,595.8,,844.05,85,,675.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,319.25,32.15,,255.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,794.7,80.03,,635.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,893.7,90,,714.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,319.25,32.15,,255.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,993,,,,Other,Not Separately reimbursable,319.25,32.15,,255.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,873.84,88,,699.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,328.78,33.11,,263.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,319.25,893.7,
NM TESTICULAR W/FLOW,23047,CDM,341,RC,78761,HCPCS,Outpatient,,,993.75,596.25,,844.69,85,,675.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,319.49,32.15,,255.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,795.3,80.03,,636.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,894.38,90,,715.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,319.49,32.15,,255.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,319.49,32.15,,255.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,874.5,88,,699.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.03,33.11,,263.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,319.49,894.38,
BARIUM ENEMA W AIR CONTRAST,22088,CDM,320,RC,74280,HCPCS,Outpatient,,,994.75,596.85,,845.54,85,,676.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.1,80.03,,636.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,895.28,90,,716.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,875.38,88,,700.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.36,33.11,,263.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,319.81,895.28,
FLUORO GREATER THAN 1 HR,22115,CDM,320,RC,76001,HCPCS,Outpatient,,,994.75,596.85,,845.54,85,,676.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.1,80.03,,636.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,895.28,90,,716.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,994.75,,,,Other,Not Separately reimbursable,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,875.38,88,,700.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.36,33.11,,263.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,319.81,895.28,
OR FLUOR > 1 HOUR,22191,CDM,320,RC,76001,HCPCS,Outpatient,,,994.75,596.85,,845.54,85,,676.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.1,80.03,,636.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,895.28,90,,716.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,994.75,,,,Other,Not Separately reimbursable,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,875.38,88,,700.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.36,33.11,,263.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,319.81,895.28,
PORT HIP OPERATIVE,22226,CDM,320,RC,73502,HCPCS,Outpatient,,,994.75,596.85,,845.54,85,,676.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.1,80.03,,636.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,895.28,90,,716.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,875.38,88,,700.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.36,33.11,,263.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,319.81,895.28,
Study of vessels on both sides of the head and neck,24038,CDM,921,RC,93880,HCPCS,Outpatient,,,994.75,596.85,,845.54,85,,676.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.1,80.03,,636.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,895.28,90,,716.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,319.81,32.15,,255.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,875.38,88,,700.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.36,33.11,,263.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,319.81,895.28,
NM BONE SPECT,23035,CDM,341,RC,78320,HCPCS,Outpatient,,,995.75,597.45,,846.39,85,,677.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.9,80.03,,637.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,896.18,90,,716.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,995.75,,,,Other,Not Separately reimbursable,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,876.26,88,,701.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.69,33.11,,263.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,320.13,896.18,
TEMP TRANSCUT PACING,1492953,CDM,450,RC,92953,HCPCS,Outpatient,,,995.75,597.45,,846.39,85,,677.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.9,80.03,,637.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,563.84,102,,,fee schedule,Pays at 102% of CMS APC rate,896.18,90,,716.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,563.84,100,,,fee schedule,Pays at 100% of CMS APC rate,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,876.26,88,,701.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.69,33.11,,263.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,320.13,896.18,
CATH 7.5FR SWAN GANZE THERMODILATION,497550,CDM,270,RC,,,Outpatient,,,996,597.6,,846.6,85,,677.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,320.21,32.15,,256.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,797.1,80.03,,637.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,896.4,90,,717.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,320.21,32.15,,256.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,996,,,,Other,Not Separately reimbursable,320.21,32.15,,256.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,876.48,88,,701.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.78,33.11,,263.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,320.21,896.4,
MPN CALR GENE MUTATION EXON 9 (MAYO),1884800,CDM,300,RC,81219,HCPCS,Outpatient,,,999.5,599.7,,849.58,85,,679.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,799.9,80.03,,639.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,124.06,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,899.55,90,,719.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,124.06,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,132.54,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,879.56,88,,703.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,136.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,132.54,899.55,
RABIES (RABAVERT) VACCINE 1ML,293434,CDM,636,RC,90675,HCPCS,Outpatient,,,999.67,599.8,,849.72,85,,679.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,328.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,800.04,80.03,,640.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,335.12,102,,,fee schedule,Pays at 102% of CMS APC rate,899.7,90,,719.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,328.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,335.12,100,,,fee schedule,Pays at 100% of CMS APC rate,328.55,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,879.71,88,,703.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,338.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,328.55,899.7,
1'ST HOUR RECOVERY,10005,CDM,710,RC,,,Outpatient,,,1004.38,602.63,,853.72,85,,682.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,322.91,32.15,,258.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,803.81,80.03,,643.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,903.94,90,,723.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,322.91,32.15,,258.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,322.91,32.15,,258.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,883.85,88,,707.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,332.55,33.11,,266.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,322.91,903.94,
HIV GENOTYPE  (MAYO),1883886,CDM,300,RC,87901,HCPCS,Outpatient,,,1005,603,,854.25,85,,683.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,804.3,80.03,,643.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,262.59,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,904.5,90,,723.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,262.59,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,109.67,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,884.4,88,,707.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.96,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,109.67,904.5,
NM PARATHYROID(MIBI SCAN),23021,CDM,341,RC,78070,HCPCS,Outpatient,,,1005,603,,854.25,85,,683.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,323.11,32.15,,258.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,804.3,80.03,,643.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,904.5,90,,723.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,323.11,32.15,,258.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,323.11,32.15,,258.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,884.4,88,,707.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,332.76,33.11,,266.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,323.11,904.5,
Radiologic examination of the pelvis,22053,CDM,320,RC,72170,HCPCS,Outpatient,,,1005.31,603.19,,854.51,85,,683.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,323.21,32.15,,258.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,804.55,80.03,,643.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,904.78,90,,723.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,323.21,32.15,,258.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,323.21,32.15,,258.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,884.67,88,,707.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,332.86,33.11,,266.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,323.21,904.78,
DEBRIDEMENT SUB Q FIRST 20 SQ CM OR LESS,11042,CDM,761,RC,11042,HCPCS,Outpatient,,,1005.31,603.19,,854.51,85,,683.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,323.21,32.15,,258.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,804.55,80.03,,643.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,904.78,90,,723.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,323.21,32.15,,258.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,323.21,32.15,,258.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,884.67,88,,707.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,332.86,33.11,,266.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,323.21,904.78,
FORCEP CUTTING 5MM X 45CM,4910097,CDM,270,RC,,,Outpatient,,,1013,607.8,,861.05,85,,688.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,325.68,32.15,,260.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,810.7,80.03,,648.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,911.7,90,,729.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,325.68,32.15,,260.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,325.68,32.15,,260.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,891.44,88,,713.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,335.4,33.11,,268.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,325.68,911.7,
CYTOCHROME P450 2C19 GENOTYPE  (MAYO),1882701,CDM,300,RC,81225,HCPCS,Outpatient,,,1017.5,610.5,,864.88,85,,691.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,244,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,814.31,80.03,,651.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,297.18,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,915.75,90,,732.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,244,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,297.18,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,244,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,895.4,88,,716.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,251.32,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,244,915.75,
HEMABATE (carboprost tromethanmin)250MCG,293515,CDM,250,RC,,,Outpatient,,,1025.87,615.52,,871.99,85,,697.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,329.82,32.15,,263.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,821,80.03,,656.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,923.28,90,,738.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,329.82,32.15,,263.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,329.82,32.15,,263.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,902.77,88,,722.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,339.67,33.11,,271.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,329.82,923.28,
PARACENTESIS ABDOMEN WITH AND WITHOUT,22368,CDM,320,RC,49083,HCPCS,Outpatient,,,1032.7,619.62,,877.8,85,,702.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,332.01,32.15,,265.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,826.47,80.03,,661.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,791.41,102,,,fee schedule,Pays at 102% of CMS APC rate,929.43,90,,743.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,332.01,32.15,,265.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,791.41,100,,,fee schedule,Pays at 100% of CMS APC rate,332.01,32.15,,265.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,908.78,88,,727.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,341.93,33.11,,273.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,332.01,929.43,
CHROMASOME ANALYSIS 20-25 CELLS  (LABCOR,2188265,CDM,310,RC,88264,HCPCS,Outpatient,,,1032.75,619.65,,877.84,85,,702.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,826.51,80.03,,661.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,147.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,929.48,90,,743.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,147.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,908.82,88,,727.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,156.73,929.48,
EXCIS BEN LSN SCLP NK HNDS FT GEN 0.6-1C,14031,CDM,450,RC,11421,HCPCS,Outpatient,,,1033,619.8,,878.05,85,,702.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,332.11,32.15,,265.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,826.71,80.03,,661.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,929.7,90,,743.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,332.11,32.15,,265.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,332.11,32.15,,265.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,909.04,88,,727.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,342.03,33.11,,273.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,332.11,929.7,
A biologic medication,292114,CDM,636,RC,J1745,HCPCS,Outpatient,,,1033,619.8,,878.05,85,,702.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,826.71,80.03,,661.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,33.29,102,,,fee schedule,Pays at 102% of CMS APC rate,929.7,90,,743.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33.29,100,,,fee schedule,Pays at 100% of CMS APC rate,32.64,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,909.04,88,,727.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.62,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.64,929.7,
ARTHROGRAM HIP BILAT,22162,CDM,320,RC,73525,HCPCS,Outpatient,,,1035,621,,879.75,85,,703.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,332.75,32.15,,266.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,828.31,80.03,,662.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,931.5,90,,745.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,332.75,32.15,,266.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,332.75,32.15,,266.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,910.8,88,,728.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,342.69,33.11,,274.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,332.75,931.5,
DEBRIDEMENT MUSCLE/FASCIA EADDT'L 20 SQ,11043,CDM,761,RC,11043,HCPCS,Outpatient,,,1036.28,621.77,,880.84,85,,704.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,333.16,32.15,,266.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,829.33,80.03,,663.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,932.65,90,,746.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,333.16,32.15,,266.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,333.16,32.15,,266.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,911.93,88,,729.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,343.11,33.11,,274.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,333.16,932.65,
ELECTRODE BALLOON PACEMAKER,497502,CDM,275,RC,,,Outpatient,,,1045,627,,888.25,85,,710.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,335.97,32.15,,268.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,836.31,80.03,,669.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,940.5,90,,752.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,335.97,32.15,,268.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,335.97,32.15,,268.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,919.6,88,,735.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,346,33.11,,276.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,335.97,940.5,
NM GALLIUM DAY 1 (MULTIPLE AREAS),23067,CDM,341,RC,78801,HCPCS,Outpatient,,,1046.5,627.9,,889.53,85,,711.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,336.45,32.15,,269.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,837.51,80.03,,670.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,941.85,90,,753.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,336.45,32.15,,269.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,336.45,32.15,,269.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,920.92,88,,736.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,346.5,33.11,,277.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,336.45,941.85,
SPECIALTY CARE TRANSPORT,530434,CDM,540,RC,A0434,HCPCS,Outpatient,,,1048.05,628.83,,890.84,85,,712.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,336.95,32.15,,269.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,838.75,80.03,,671,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,943.25,90,,754.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,336.95,32.15,,269.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,336.95,32.15,,269.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,922.28,88,,737.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,347.01,33.11,,277.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,336.95,943.25,
LUMBAR PUNCTURE,1062270,CDM,360,RC,62270,HCPCS,Outpatient,,,1049.5,629.7,,892.08,85,,713.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,839.91,80.03,,671.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,944.55,90,,755.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,923.56,88,,738.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,347.49,33.11,,277.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,337.41,944.55,
PUNCTURE OF SHUNT TUBING OR RESERVOIR FO,1461070,CDM,450,RC,61070,HCPCS,Outpatient,,,1049.5,629.7,,892.08,85,,713.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,839.91,80.03,,671.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,944.55,90,,755.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,923.56,88,,738.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,347.49,33.11,,277.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,337.41,944.55,
LUMBAR PUNCTURE,1462270,CDM,450,RC,62270,HCPCS,Outpatient,,,1049.5,629.7,,892.08,85,,713.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,839.91,80.03,,671.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,944.55,90,,755.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,923.56,88,,738.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,347.49,33.11,,277.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,337.41,944.55,
INTERCOSTAL NERVE BLOCK SINGLE,1464420,CDM,450,RC,64420,HCPCS,Outpatient,,,1049.5,629.7,,892.08,85,,713.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,839.91,80.03,,671.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,944.55,90,,755.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,923.56,88,,738.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,347.49,33.11,,277.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,337.41,944.55,
BLOOD PATCH,149022,CDM,761,RC,62273,HCPCS,Outpatient,,,1049.5,629.7,,892.08,85,,713.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,839.91,80.03,,671.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,944.55,90,,755.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,337.41,32.15,,269.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,923.56,88,,738.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,347.49,33.11,,277.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,337.41,944.55,
ADD  AMP 15 MIN,11010,CDM,360,RC,,,Outpatient,,,1054.06,632.44,,895.95,85,,716.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,338.88,32.15,,271.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,843.56,80.03,,674.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,948.65,90,,758.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,338.88,32.15,,271.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,338.88,32.15,,271.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,927.57,88,,742.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,349,33.11,,279.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,338.88,948.65,
O/T WRIST/HAND SPLINT WITH OUTRIGGER FIT,3937,CDM,274,RC,L3916,HCPCS,Outpatient,,,1055.75,633.45,,897.39,85,,717.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,339.42,32.15,,271.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,844.92,80.03,,675.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,950.18,90,,760.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,339.42,32.15,,271.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,339.42,32.15,,271.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,929.06,88,,743.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,349.56,33.11,,279.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,339.42,950.18,
FORCEP CUTTING HALO 5MM X 33CM,4910098,CDM,270,RC,,,Outpatient,,,1060.5,636.3,,901.43,85,,721.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,340.95,32.15,,272.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,848.72,80.03,,678.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,954.45,90,,763.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,340.95,32.15,,272.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,340.95,32.15,,272.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,933.24,88,,746.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,351.13,33.11,,280.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,340.95,954.45,
STAPLER 33MM HEMORRHOID 3.5MM STAPLE,4980118,CDM,270,RC,,,Outpatient,,,1067.25,640.35,,907.16,85,,725.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,343.12,32.15,,274.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,854.12,80.03,,683.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,960.53,90,,768.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,343.12,32.15,,274.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,343.12,32.15,,274.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,939.18,88,,751.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,353.37,33.11,,282.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,343.12,960.53,
STAPLER 33MM HEMORRHOID 4.8MM STAPLE,4980119,CDM,270,RC,,,Outpatient,,,1067.25,640.35,,907.16,85,,725.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,343.12,32.15,,274.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,854.12,80.03,,683.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,960.53,90,,768.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,343.12,32.15,,274.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,343.12,32.15,,274.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,939.18,88,,751.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,353.37,33.11,,282.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,343.12,960.53,
SIGMOIDOSCOPY,9055,CDM,750,RC,,,Outpatient,,,1071.25,642.75,,910.56,85,,728.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,344.41,32.15,,275.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,857.32,80.03,,685.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,964.13,90,,771.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,344.41,32.15,,275.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,344.41,32.15,,275.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,942.7,88,,754.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,354.69,33.11,,283.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,344.41,964.13,
BIOPSY PROBE 10 GAUGE INTRODUCER KIT,27095,CDM,270,RC,,,Outpatient,,,1074.25,644.55,,913.11,85,,730.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,345.37,32.15,,276.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,859.72,80.03,,687.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,966.83,90,,773.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,345.37,32.15,,276.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,345.37,32.15,,276.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.34,88,,756.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,355.68,33.11,,284.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,345.37,966.83,
I & D PILONIDAL CYST,1410080,CDM,450,RC,10080,HCPCS,Outpatient,,,1078,646.8,,916.3,85,,733.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,346.58,32.15,,277.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,862.72,80.03,,690.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,970.2,90,,776.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,346.58,32.15,,277.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,346.58,32.15,,277.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,948.64,88,,758.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,356.93,33.11,,285.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,346.58,970.2,
KIT IMPLANT TEGRESS,4999002,CDM,278,RC,,,Outpatient,,,1080.75,648.45,,918.64,85,,734.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,347.46,32.15,,277.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,864.92,80.03,,691.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,972.68,90,,778.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,347.46,32.15,,277.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,347.46,32.15,,277.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,951.06,88,,760.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,357.84,33.11,,286.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,347.46,972.68,
NM RENAL W/FLOW,23016,CDM,341,RC,78701,HCPCS,Outpatient,,,1084.75,650.85,,922.04,85,,737.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,868.13,80.03,,694.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,976.28,90,,781.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,954.58,88,,763.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,359.16,33.11,,287.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,348.75,976.28,
NM BONE SCAN THREE PHASE STUDY,23019,CDM,341,RC,78315,HCPCS,Outpatient,,,1084.75,650.85,,922.04,85,,737.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,868.13,80.03,,694.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,976.28,90,,781.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,954.58,88,,763.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,359.16,33.11,,287.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,348.75,976.28,
NM RBC TAGGING,23053,CDM,341,RC,78140,HCPCS,Outpatient,,,1084.75,650.85,,922.04,85,,737.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,868.13,80.03,,694.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,976.28,90,,781.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,348.75,32.15,,279,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,954.58,88,,763.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,359.16,33.11,,287.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,348.75,976.28,
ELBOW REDUCTION/C ANES,1424805,CDM,450,RC,,,Outpatient,,,1088.25,652.95,,925.01,85,,740.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,349.87,32.15,,279.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,870.93,80.03,,696.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,979.43,90,,783.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,349.87,32.15,,279.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,349.87,32.15,,279.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,957.66,88,,766.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,360.32,33.11,,288.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,349.87,979.43,
NM VENOUS THROMBOSIS,2378457,CDM,341,RC,78457,HCPCS,Outpatient,,,1096.25,657.75,,931.81,85,,745.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,352.44,32.15,,281.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,877.33,80.03,,701.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,986.63,90,,789.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,352.44,32.15,,281.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,352.44,32.15,,281.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,964.7,88,,771.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,362.97,33.11,,290.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,352.44,986.63,
Scan using a radioactive medication (radiopharmaceutical) to take pictures or images of the thyroid gland.,23036,CDM,341,RC,78014,HCPCS,Outpatient,,,1102.75,661.65,,937.34,85,,749.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,354.53,32.15,,283.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,882.53,80.03,,706.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,992.48,90,,793.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,354.53,32.15,,283.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,354.53,32.15,,283.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,970.42,88,,776.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,365.12,33.11,,292.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,354.53,992.48,
"Emergency department visit, problem with significant threat to life or function",14022,CDM,450,RC,99285,HCPCS,Outpatient,,,1104.95,662.97,,939.21,85,,751.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,884.29,80.03,,707.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,525.47,102,,,fee schedule,Pays at 102% of CMS APC rate,994.46,90,,795.57,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,525.47,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,972.36,88,,777.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385,994.46,
BLOOD PATCH,9022,CDM,761,RC,62273,HCPCS,Outpatient,,,1105.5,663.3,,939.68,85,,751.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,355.42,32.15,,284.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,884.73,80.03,,707.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,994.95,90,,795.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,355.42,32.15,,284.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,355.42,32.15,,284.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,972.84,88,,778.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,366.03,33.11,,292.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,355.42,994.95,
EXTENSION QUADE,4999921,CDM,278,RC,C1883,HCPCS,Outpatient,,,1105.75,663.45,,939.89,85,,751.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,355.5,32.15,,284.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,884.93,80.03,,707.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,995.18,90,,796.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,355.5,32.15,,284.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,355.5,32.15,,284.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,973.06,88,,778.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,366.11,33.11,,292.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,355.5,995.18,
DEBRIDEMENT BONEEA ADDT'L 20 SQ CM,11047,CDM,761,RC,11047,HCPCS,Outpatient,,,1111.75,667.05,,944.99,85,,755.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,357.43,32.15,,285.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,889.73,80.03,,711.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1000.58,90,,800.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,357.43,32.15,,285.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,357.43,32.15,,285.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,978.34,88,,782.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,368.1,33.11,,294.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,357.43,1000.58,
I & D PILONIDAL CYST-COMPLICATED,1410081,CDM,450,RC,10081,HCPCS,Outpatient,,,1115.75,669.45,,948.39,85,,758.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,892.93,80.03,,714.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.18,90,,803.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.86,88,,785.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.42,33.11,,295.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.71,1004.18,
EXCISION BENIGN LESION,1411403,CDM,450,RC,11403,HCPCS,Outpatient,,,1115.75,669.45,,948.39,85,,758.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,892.93,80.03,,714.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.18,90,,803.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.86,88,,785.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.42,33.11,,295.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.71,1004.18,
EXPLORATION OF PENETRATING WOUND EXTREMI,1420103,CDM,450,RC,20103,HCPCS,Outpatient,,,1115.75,669.45,,948.39,85,,758.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,892.93,80.03,,714.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.18,90,,803.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.86,88,,785.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.42,33.11,,295.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.71,1004.18,
MONITORING FLUID PRESSURE FOR COMPARTMEN,1420950,CDM,450,RC,20950,HCPCS,Outpatient,,,1115.75,669.45,,948.39,85,,758.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,892.93,80.03,,714.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.18,90,,803.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.86,88,,785.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.42,33.11,,295.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.71,1004.18,
"REMOVAL OF F.B. FOOT, SUB",1428190,CDM,450,RC,28190,HCPCS,Outpatient,,,1115.75,669.45,,948.39,85,,758.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,892.93,80.03,,714.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.18,90,,803.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.86,88,,785.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.42,33.11,,295.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.71,1004.18,
"I & D, ABSCESS, CYST, VESTIBULE OF MOUTH",1440800,CDM,450,RC,40800,HCPCS,Outpatient,,,1115.75,669.45,,948.39,85,,758.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,892.93,80.03,,714.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.18,90,,803.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.86,88,,785.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.42,33.11,,295.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.71,1004.18,
I & D EXT EAR,1469000,CDM,450,RC,69000,HCPCS,Outpatient,,,1115.75,669.45,,948.39,85,,758.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,892.93,80.03,,714.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.18,90,,803.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,358.71,32.15,,286.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.86,88,,785.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.42,33.11,,295.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.71,1004.18,
NM ACUTE THROMBOSIS,23044,CDM,341,RC,78499,HCPCS,Outpatient,,,1116.5,669.9,,949.03,85,,759.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,358.95,32.15,,287.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,893.53,80.03,,714.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1004.85,90,,803.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,358.95,32.15,,287.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,358.95,32.15,,287.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,982.52,88,,786.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,369.67,33.11,,295.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,358.95,1004.85,
NM BRAIN,23063,CDM,341,RC,78600,HCPCS,Outpatient,,,1119.75,671.85,,951.79,85,,761.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,360,32.15,,288,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,896.14,80.03,,716.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1007.78,90,,806.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,360,32.15,,288,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,360,32.15,,288,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,985.38,88,,788.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,370.75,33.11,,296.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,360,1007.78,
"CT scan, pelvis, with contrast",26020,CDM,352,RC,72193,HCPCS,Outpatient,,,1125,675,,956.25,85,,765,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,361.69,32.15,,289.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,900.34,80.03,,720.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1012.5,90,,810,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,361.69,32.15,,289.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,361.69,32.15,,289.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,990,88,,792,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,372.49,33.11,,297.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,361.69,1012.5,
NM BRAIN SCAN COMPLETE/DYN,23013,CDM,341,RC,78606,HCPCS,Outpatient,,,1125.75,675.45,,956.89,85,,765.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,361.93,32.15,,289.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,900.94,80.03,,720.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1013.18,90,,810.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,361.93,32.15,,289.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,361.93,32.15,,289.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,990.66,88,,792.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,372.74,33.11,,298.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,361.93,1013.18,
PREMARIN VAG CRM (conj estrogen) 30GM,292018,CDM,250,RC,,,Outpatient,,,1129.65,677.79,,960.2,85,,768.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,363.18,32.15,,290.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,904.06,80.03,,723.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1016.69,90,,813.35,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,363.18,32.15,,290.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,363.18,32.15,,290.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,994.09,88,,795.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,374.03,33.11,,299.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,363.18,1016.69,
LUPRON DEPOT (leuprolide) 3.75MG INJ *NF,293449,CDM,636,RC,J1950,HCPCS,Outpatient,,,1130,678,,960.5,85,,768.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,904.34,80.03,,723.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1554.82,102,,,fee schedule,Pays at 102% of CMS APC rate,1017,90,,813.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1554.82,100,,,fee schedule,Pays at 100% of CMS APC rate,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,994.4,88,,795.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1570.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,904.34,1524.34,
ASPIRATION BLADDER BY NEEDLE,1451000,CDM,450,RC,51100,HCPCS,Outpatient,,,1136.5,681.9,,966.03,85,,772.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,365.38,32.15,,292.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,909.54,80.03,,727.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,205.98,102,,,fee schedule,Pays at 102% of CMS APC rate,1022.85,90,,818.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,365.38,32.15,,292.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.98,100,,,fee schedule,Pays at 100% of CMS APC rate,365.38,32.15,,292.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1000.12,88,,800.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,376.3,33.11,,301.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,365.38,1022.85,
NM THYROID IMAGING WITH VASCULAR FLOW,2378011,CDM,341,RC,78013,HCPCS,Outpatient,,,1144.5,686.7,,972.83,85,,778.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,367.96,32.15,,294.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,915.94,80.03,,732.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1030.05,90,,824.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,367.96,32.15,,294.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,367.96,32.15,,294.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1007.16,88,,805.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,378.94,33.11,,303.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,367.96,1030.05,
CT scan of the thorax with dye,26012,CDM,352,RC,71260,HCPCS,Outpatient,,,1149,689.4,,976.65,85,,781.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,369.4,32.15,,295.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,919.54,80.03,,735.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1034.1,90,,827.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,369.4,32.15,,295.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,369.4,32.15,,295.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1011.12,88,,808.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,380.43,33.11,,304.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,369.4,1034.1,
PURAPLY AM 2 X 4 COMMERICAL 8 SQ CM,49825,CDM,270,RC,,,Outpatient,,,1150,690,,977.5,85,,782,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,369.73,32.15,,295.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,920.35,80.03,,736.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1035,90,,828,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,369.73,32.15,,295.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,369.73,32.15,,295.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1012,88,,809.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,380.77,33.11,,304.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,369.73,1035,
"Emergency department visit, problem of high severity",14008,CDM,450,RC,99284,HCPCS,Outpatient,,,1150,690,,977.5,85,,782,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,920.35,80.03,,736.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,365.84,102,,,fee schedule,Pays at 102% of CMS APC rate,1035,90,,828,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.84,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1012,88,,809.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385,1035,
"Emergency department visit, problem of high severity",14021,CDM,450,RC,99284,HCPCS,Outpatient,,,1150,690,,977.5,85,,782,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,920.35,80.03,,736.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,365.84,102,,,fee schedule,Pays at 102% of CMS APC rate,1035,90,,828,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.84,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1012,88,,809.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385,1035,
NM GALLIUM WB DAY 1,23064,CDM,341,RC,78806,HCPCS,Outpatient,,,1152,691.2,,979.2,85,,783.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,921.95,80.03,,737.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1036.8,90,,829.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1013.76,88,,811.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,381.43,33.11,,305.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,370.37,1036.8,
NM GALLIUM WB DAY 2,23065,CDM,341,RC,78804,HCPCS,Outpatient,,,1152,691.2,,979.2,85,,783.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,921.95,80.03,,737.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1036.8,90,,829.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1013.76,88,,811.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,381.43,33.11,,305.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,370.37,1036.8,
NM TUMOR LOC WHOLE BODY,23066,CDM,341,RC,78804,HCPCS,Outpatient,,,1152,691.2,,979.2,85,,783.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,921.95,80.03,,737.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1036.8,90,,829.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,370.37,32.15,,296.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1013.76,88,,811.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,381.43,33.11,,305.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,370.37,1036.8,
IP  HEMODIALYSIS - ESRD,17001,CDM,801,RC,90935,HCPCS,Outpatient,,,1160.63,696.38,,986.54,85,,789.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,373.14,32.15,,298.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,928.85,80.03,,743.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,604.48,102,,,fee schedule,Pays at 102% of CMS APC rate,1044.57,90,,835.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,373.14,32.15,,298.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,604.48,100,,,fee schedule,Pays at 100% of CMS APC rate,373.14,32.15,,298.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1021.35,88,,817.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,384.28,33.11,,307.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,373.14,1044.57,
REMOVAL OF GASTRIC RESTRUCTIVE DEVICE,1443999,CDM,450,RC,43999,HCPCS,Outpatient,,,1164.4,698.64,,989.74,85,,791.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,374.35,32.15,,299.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,931.87,80.03,,745.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,791.41,102,,,fee schedule,Pays at 102% of CMS APC rate,1047.96,90,,838.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,374.35,32.15,,299.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,791.41,100,,,fee schedule,Pays at 100% of CMS APC rate,374.35,32.15,,299.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1024.67,88,,819.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,385.53,33.11,,308.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,374.35,1047.96,
VENTILATOR SUBSEQUENT PER DAY,30056,CDM,410,RC,94003,HCPCS,Outpatient,,,1166.66,700,,991.66,85,,793.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,375.08,32.15,,300.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,933.68,80.03,,746.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,533.72,102,,,fee schedule,Pays at 102% of CMS APC rate,1049.99,90,,839.99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,375.08,32.15,,300.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,533.72,100,,,fee schedule,Pays at 100% of CMS APC rate,375.08,32.15,,300.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1026.66,88,,821.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,386.28,33.11,,309.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,375.08,1049.99,
SEALER/DIVIDER LAP LIGASURE ATLAS 37CM,4999046,CDM,270,RC,A4649,HCPCS,Outpatient,,,1171.75,703.05,,995.99,85,,796.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,376.72,32.15,,301.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,937.75,80.03,,750.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1054.58,90,,843.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,376.72,32.15,,301.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,376.72,32.15,,301.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1031.14,88,,824.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,387.97,33.11,,310.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,376.72,1054.58,
NM HIDA,23045,CDM,341,RC,78227,HCPCS,Outpatient,,,1172.75,703.65,,996.84,85,,797.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,377.04,32.15,,301.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,938.55,80.03,,750.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1055.48,90,,844.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,377.04,32.15,,301.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,377.04,32.15,,301.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1032.02,88,,825.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,388.3,33.11,,310.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,377.04,1055.48,
INITIAL VENTILATOR PER DAY,30058,CDM,410,RC,94002,HCPCS,Outpatient,,,1172.81,703.69,,996.89,85,,797.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,377.06,32.15,,301.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,938.6,80.03,,750.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,533.72,102,,,fee schedule,Pays at 102% of CMS APC rate,1055.53,90,,844.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,377.06,32.15,,301.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,533.72,100,,,fee schedule,Pays at 100% of CMS APC rate,377.06,32.15,,301.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1032.07,88,,825.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,388.32,33.11,,310.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,377.06,1055.53,
CT scan of neck with dye,26010,CDM,351,RC,70491,HCPCS,Outpatient,,,1176.75,706.05,,1000.24,85,,800.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,378.33,32.15,,302.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,941.75,80.03,,753.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1059.08,90,,847.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,378.33,32.15,,302.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,378.33,32.15,,302.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1035.54,88,,828.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,389.62,33.11,,311.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,378.33,1059.08,
IMPLANT DELIVERY SYSTEM TENODESIS SCREW,4999070,CDM,270,RC,,,Outpatient,,,1178.25,706.95,,1001.51,85,,801.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,378.81,32.15,,303.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,942.95,80.03,,754.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1060.43,90,,848.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,378.81,32.15,,303.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,378.81,32.15,,303.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1036.86,88,,829.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,390.12,33.11,,312.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,378.81,1060.43,
SET PNEUMOTHORAX 9F 29CM 18G 20CM,493697,CDM,270,RC,,,Outpatient,,,1180.5,708.3,,1003.43,85,,802.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.53,32.15,,303.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,944.75,80.03,,755.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1062.45,90,,849.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.53,32.15,,303.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,379.53,32.15,,303.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1038.84,88,,831.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,390.86,33.11,,312.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.53,1062.45,
CT LUMBAR W CONTRAST,26019,CDM,352,RC,72132,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
MRI LUMBAR W CONTRAST,27009,CDM,610,RC,72149,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
MRI EXT UP NON-JNT WWO CONTRAST LT,27014,CDM,610,RC,73220,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
MRA CAROTID WWO CONTRAST,27033,CDM,610,RC,70549,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
MRI EXT UP JOINT WWO CONTRAST LT,27220,CDM,610,RC,73223,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
MRI of lower extremity joint (knee/ankle) with and without dye,27054,CDM,614,RC,73723,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
MRI BREAST SCREENING,27081,CDM,614,RC,77049,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
MRI of lower extremity joint (knee/ankle) with and without dye,27623,CDM,614,RC,73723,HCPCS,Outpatient,,,1181,708.6,,1003.85,85,,803.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,945.15,80.03,,756.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1062.9,90,,850.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,379.69,32.15,,303.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1039.28,88,,831.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.03,33.11,,312.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,379.69,1062.9,
Complete bilateral study of the extremities,24023,CDM,921,RC,93970,HCPCS,Outpatient,,,1183.67,710.2,,1006.12,85,,804.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,380.55,32.15,,304.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,947.29,80.03,,757.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1065.3,90,,852.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,380.55,32.15,,304.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,380.55,32.15,,304.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1041.63,88,,833.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,391.91,33.11,,313.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,380.55,1065.3,
REPAIR LIP FULL THICKNESS VERMILION ONLY,40650,CDM,450,RC,40650,HCPCS,Outpatient,,,1190.25,714.15,,1011.71,85,,809.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,382.67,32.15,,306.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,952.56,80.03,,762.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,437.94,102,,,fee schedule,Pays at 102% of CMS APC rate,1071.23,90,,856.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,382.67,32.15,,306.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.94,100,,,fee schedule,Pays at 100% of CMS APC rate,382.67,32.15,,306.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1047.42,88,,837.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,394.09,33.11,,315.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,382.67,1071.23,
NUSHIELD 2 X 4 CM GRAFT HUMAN TISSUE,49826,CDM,270,RC,,,Outpatient,,,1200,720,,1020,85,,816,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385.8,32.15,,308.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,960.36,80.03,,768.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1080,90,,864,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385.8,32.15,,308.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,385.8,32.15,,308.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1056,88,,844.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,397.32,33.11,,317.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385.8,1080,
US EXTREMITY BILATERAL ARTERIAL,24128,CDM,921,RC,93925,HCPCS,Outpatient,,,1202.75,721.65,,1022.34,85,,817.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,386.68,32.15,,309.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,962.56,80.03,,770.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1082.48,90,,865.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,386.68,32.15,,309.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,386.68,32.15,,309.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1058.42,88,,846.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,398.23,33.11,,318.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,386.68,1082.48,
NM WBC SCAN CERETEC,23043,CDM,341,RC,78805,HCPCS,Outpatient,,,1203.5,722.1,,1022.98,85,,818.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,386.93,32.15,,309.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,963.16,80.03,,770.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083.15,90,,866.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,386.93,32.15,,309.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,386.93,32.15,,309.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1059.08,88,,847.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,398.48,33.11,,318.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,386.93,1083.15,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",2378306,CDM,341,RC,78306,HCPCS,Outpatient,,,1205,723,,1024.25,85,,819.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,387.41,32.15,,309.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,964.36,80.03,,771.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1084.5,90,,867.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,387.41,32.15,,309.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,387.41,32.15,,309.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1060.4,88,,848.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,398.98,33.11,,319.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,387.41,1084.5,
BONE/JOINT THREE PHASE STUDY,2378315,CDM,341,RC,78315,HCPCS,Outpatient,,,1205,723,,1024.25,85,,819.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,387.41,32.15,,309.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,964.36,80.03,,771.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1084.5,90,,867.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,387.41,32.15,,309.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,387.41,32.15,,309.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1060.4,88,,848.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,398.98,33.11,,319.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,387.41,1084.5,
SEALER/DIVIDER LAP LIGASURE V 5MM X 37CM,4980093,CDM,270,RC,A4649,HCPCS,Outpatient,,,1212.25,727.35,,1030.41,85,,824.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,389.74,32.15,,311.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,970.16,80.03,,776.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1091.03,90,,872.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,389.74,32.15,,311.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,389.74,32.15,,311.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1066.78,88,,853.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,401.38,33.11,,321.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,389.74,1091.03,
SEALER/DIVIDER LAP LIGASURE BT 5MMX37CM,4980100,CDM,270,RC,A4649,HCPCS,Outpatient,,,1212.25,727.35,,1030.41,85,,824.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,389.74,32.15,,311.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,970.16,80.03,,776.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1091.03,90,,872.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,389.74,32.15,,311.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,389.74,32.15,,311.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1066.78,88,,853.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,401.38,33.11,,321.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,389.74,1091.03,
TRANSFUSION  BLOOD OR COMPONENT,1436430,CDM,391,RC,36430,HCPCS,Outpatient,,,1213.44,728.06,,1031.42,85,,825.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,390.12,32.15,,312.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,971.12,80.03,,776.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,390.9,102,,,fee schedule,Pays at 102% of CMS APC rate,1092.1,90,,873.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,390.12,32.15,,312.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.9,100,,,fee schedule,Pays at 100% of CMS APC rate,390.12,32.15,,312.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1067.83,88,,854.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,401.77,33.11,,321.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,390.12,1092.1,
COMBIVENT RESP (ipratrop/albut)INH 14.7G,292207,CDM,250,RC,J3535,HCPCS,Outpatient,,,1226.4,735.84,,1042.44,85,,833.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,394.29,32.15,,315.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.49,80.03,,785.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1103.76,90,,883.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,394.29,32.15,,315.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,394.29,32.15,,315.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1079.23,88,,863.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,406.06,33.11,,324.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,394.29,1103.76,
TRUCLEAR ULTRA PLUS DEVISE,4999947,CDM,272,RC,,,Outpatient,,,1235.75,741.45,,1050.39,85,,840.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,397.29,32.15,,317.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,988.97,80.03,,791.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1112.18,90,,889.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,397.29,32.15,,317.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,397.29,32.15,,317.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1087.46,88,,869.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,409.16,33.11,,327.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,397.29,1112.18,
CT Scan of the face and jaw without dye,26070,CDM,351,RC,70486,HCPCS,Outpatient,,,1244,746.4,,1057.4,85,,845.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,399.95,32.15,,319.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,995.57,80.03,,796.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1119.6,90,,895.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,399.95,32.15,,319.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,399.95,32.15,,319.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1094.72,88,,875.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,411.89,33.11,,329.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,399.95,1119.6,
LIGASURE 37CM BLUNT TIP LAPAROSCOPIC,4980117,CDM,270,RC,,,Outpatient,,,1245.25,747.15,,1058.46,85,,846.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,400.35,32.15,,320.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,996.57,80.03,,797.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1120.73,90,,896.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,400.35,32.15,,320.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,400.35,32.15,,320.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1095.82,88,,876.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,412.3,33.11,,329.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,400.35,1120.73,
LEVEL 3 SKIN PROCEDURES,9380,CDM,790,RC,,,Outpatient,,,1262.75,757.65,,1073.34,85,,858.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,405.97,32.15,,324.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1010.58,80.03,,808.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1136.48,90,,909.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,405.97,32.15,,324.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,405.97,32.15,,324.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1111.22,88,,888.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,418.1,33.11,,334.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,405.97,1136.48,
NM GASTROESOPHAGEAL REFLUX,2378262,CDM,341,RC,78262,HCPCS,Outpatient,,,1264.75,758.85,,1075.04,85,,860.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,406.62,32.15,,325.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1012.18,80.03,,809.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1138.28,90,,910.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,406.62,32.15,,325.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,406.62,32.15,,325.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1112.98,88,,890.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,418.76,33.11,,335.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,406.62,1138.28,
GASTRIC EMPTYING STUDY,2378264,CDM,341,RC,78264,HCPCS,Outpatient,,,1264.75,758.85,,1075.04,85,,860.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,406.62,32.15,,325.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1012.18,80.03,,809.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1138.28,90,,910.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,406.62,32.15,,325.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,406.62,32.15,,325.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1112.98,88,,890.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,418.76,33.11,,335.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,406.62,1138.28,
BRONCHOSCOPY,9045,CDM,360,RC,,,Outpatient,,,1285.5,771.3,,1092.68,85,,874.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,413.29,32.15,,330.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1028.79,80.03,,823.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1156.95,90,,925.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,413.29,32.15,,330.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,413.29,32.15,,330.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1131.24,88,,904.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,425.63,33.11,,340.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,413.29,1156.95,
ENDOSCOPY,9100,CDM,360,RC,,,Outpatient,,,1285.5,771.3,,1092.68,85,,874.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,413.29,32.15,,330.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1028.79,80.03,,823.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1156.95,90,,925.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,413.29,32.15,,330.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,413.29,32.15,,330.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1131.24,88,,904.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,425.63,33.11,,340.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,413.29,1156.95,
VENOGRAM EXTREMITY BILAT,22109,CDM,320,RC,75822,HCPCS,Outpatient,,,1294.25,776.55,,1100.11,85,,880.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,416.1,32.15,,332.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1035.79,80.03,,828.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,1164.83,90,,931.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,416.1,32.15,,332.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,416.1,32.15,,332.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1138.94,88,,911.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,428.53,33.11,,342.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,416.1,1164.83,
(E) NM GASTRIC EMPTYING,23052,CDM,341,RC,78264,HCPCS,Outpatient,,,1294.25,776.55,,1100.11,85,,880.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,416.1,32.15,,332.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1035.79,80.03,,828.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1164.83,90,,931.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,416.1,32.15,,332.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,416.1,32.15,,332.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1138.94,88,,911.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,428.53,33.11,,342.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,416.1,1164.83,
ANCHOR SUTURE 5.5 CROSSFT,4999060,CDM,270,RC,,,Outpatient,,,1302,781.2,,1106.7,85,,885.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,418.59,32.15,,334.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1041.99,80.03,,833.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1171.8,90,,937.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,418.59,32.15,,334.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,418.59,32.15,,334.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1145.76,88,,916.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,431.09,33.11,,344.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,418.59,1171.8,
GASTROSCOPY,9025,CDM,750,RC,,,Outpatient,,,1306.5,783.9,,1110.53,85,,888.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,420.04,32.15,,336.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1045.59,80.03,,836.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1175.85,90,,940.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,420.04,32.15,,336.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,420.04,32.15,,336.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1149.72,88,,919.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,432.58,33.11,,346.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,420.04,1175.85,
CT SOFT TISS NECK WWO CONTRAST,26068,CDM,351,RC,70492,HCPCS,Outpatient,,,1308.25,784.95,,1112.01,85,,889.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1046.99,80.03,,837.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1177.43,90,,941.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1151.26,88,,921.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,433.16,33.11,,346.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,420.6,1177.43,
CT of abdomen with and without dye,26029,CDM,352,RC,74170,HCPCS,Outpatient,,,1308.25,784.95,,1112.01,85,,889.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1046.99,80.03,,837.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1177.43,90,,941.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1151.26,88,,921.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,433.16,33.11,,346.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,420.6,1177.43,
MRA ABDOMEN WITH OR  WITHOUT CONTRAST,27045,CDM,618,RC,74185,HCPCS,Outpatient,,,1308.25,784.95,,1112.01,85,,889.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1046.99,80.03,,837.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1177.43,90,,941.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,420.6,32.15,,336.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1151.26,88,,921.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,433.16,33.11,,346.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,420.6,1177.43,
STAPLER ENDO GIA 30MM CRVD ARTICULATING,4999017,CDM,270,RC,,,Outpatient,,,1312,787.2,,1115.2,85,,892.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,421.81,32.15,,337.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1049.99,80.03,,839.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1180.8,90,,944.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,421.81,32.15,,337.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,421.81,32.15,,337.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1154.56,88,,923.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,434.4,33.11,,347.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,421.81,1180.8,
NM LIVER SPLEEN SCAN,23004,CDM,341,RC,78215,HCPCS,Outpatient,,,1314.5,788.7,,1117.33,85,,893.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1051.99,80.03,,841.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1183.05,90,,946.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1156.76,88,,925.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,435.23,33.11,,348.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,422.61,1183.05,
NM LUNG SCAN PERFUSION,23010,CDM,341,RC,78580,HCPCS,Outpatient,,,1314.5,788.7,,1117.33,85,,893.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1051.99,80.03,,841.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1183.05,90,,946.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1156.76,88,,925.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,435.23,33.11,,348.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,422.61,1183.05,
NM LUNG SCAN VENTILATION,23012,CDM,341,RC,78579,HCPCS,Outpatient,,,1314.5,788.7,,1117.33,85,,893.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1051.99,80.03,,841.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1183.05,90,,946.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1156.76,88,,925.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,435.23,33.11,,348.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,422.61,1183.05,
LIVER AND SPLEEN IMAGING,2378215,CDM,341,RC,78215,HCPCS,Outpatient,,,1314.5,788.7,,1117.33,85,,893.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1051.99,80.03,,841.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1183.05,90,,946.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,422.61,32.15,,338.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1156.76,88,,925.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,435.23,33.11,,348.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,422.61,1183.05,
VIRAL RESPIRATORY PANEL PCR (MAYO),1887254,CDM,300,RC,0099U,HCPCS,Outpatient,,,1318.75,791.25,,1120.94,85,,896.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,423.98,32.15,,339.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1055.4,80.03,,844.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1186.88,90,,949.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,423.98,32.15,,339.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,423.98,32.15,,339.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1160.5,88,,928.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,436.64,33.11,,349.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,423.98,1186.88,
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,22171,CDM,320,RC,64483,HCPCS,Outpatient,,,1320,792,,1122,85,,897.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1056.4,80.03,,845.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,1188,90,,950.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1161.6,88,,929.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.05,33.11,,349.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,424.38,1188,
FACET INJ CERV/THORACIC BIL,22305,CDM,320,RC,64470,HCPCS,Outpatient,,,1320,792,,1122,85,,897.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1056.4,80.03,,845.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1188,90,,950.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1161.6,88,,929.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.05,33.11,,349.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,424.38,1188,
FACET INJ CERV/THORACIC EA ADD BIL,22307,CDM,320,RC,64472,HCPCS,Outpatient,,,1320,792,,1122,85,,897.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1056.4,80.03,,845.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1188,90,,950.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1161.6,88,,929.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.05,33.11,,349.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,424.38,1188,
FACET INJ LUMB/SACR BIL,22309,CDM,320,RC,64475,HCPCS,Outpatient,,,1320,792,,1122,85,,897.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1056.4,80.03,,845.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1188,90,,950.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1161.6,88,,929.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.05,33.11,,349.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,424.38,1188,
FACET INJ LUMB/SACR EA ADD BIL,22311,CDM,320,RC,64476,HCPCS,Outpatient,,,1320,792,,1122,85,,897.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1056.4,80.03,,845.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1188,90,,950.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1161.6,88,,929.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.05,33.11,,349.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,424.38,1188,
NERVE ROOT BLOCK LUMBAR EA ADDITIONAL,22346,CDM,320,RC,64484,HCPCS,Outpatient,,,1320,792,,1122,85,,897.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1056.4,80.03,,845.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1188,90,,950.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,424.38,32.15,,339.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1161.6,88,,929.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.05,33.11,,349.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,424.38,1188,
INTERCOSTAL NERVE BLOCK MULTIPLE,1464421,CDM,450,RC,64421,HCPCS,Outpatient,,,1321.75,793.05,,1123.49,85,,898.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,424.94,32.15,,339.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1057.8,80.03,,846.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,1189.58,90,,951.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,424.94,32.15,,339.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,424.94,32.15,,339.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1163.14,88,,930.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.63,33.11,,350.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,424.94,1189.58,
MRI of lower extremity joint (knee/ankle) without dye,27032,CDM,614,RC,73721,HCPCS,Outpatient,,,1322.75,793.65,,1124.34,85,,899.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,425.26,32.15,,340.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1058.6,80.03,,846.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1190.48,90,,952.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,425.26,32.15,,340.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,425.26,32.15,,340.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1164.02,88,,931.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.96,33.11,,350.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,425.26,1190.48,
MRI of lower extremity joint (knee/ankle) without dye,27055,CDM,614,RC,73721,HCPCS,Outpatient,,,1322.75,793.65,,1124.34,85,,899.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,425.26,32.15,,340.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1058.6,80.03,,846.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1190.48,90,,952.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,425.26,32.15,,340.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,425.26,32.15,,340.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1164.02,88,,931.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,437.96,33.11,,350.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,425.26,1190.48,
LEVEL 1 VASCULAR PROCEDURES,9180,CDM,360,RC,,,Outpatient,,,1324.75,794.85,,1126.04,85,,900.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,425.91,32.15,,340.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1060.2,80.03,,848.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1192.28,90,,953.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,425.91,32.15,,340.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,425.91,32.15,,340.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1165.78,88,,932.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,438.62,33.11,,350.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,425.91,1192.28,
CARDIOVERSION,1492960,CDM,450,RC,92960,HCPCS,Outpatient,,,1326.75,796.05,,1127.74,85,,902.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,426.55,32.15,,341.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1061.8,80.03,,849.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,563.84,102,,,fee schedule,Pays at 102% of CMS APC rate,1194.08,90,,955.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,426.55,32.15,,341.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,563.84,100,,,fee schedule,Pays at 100% of CMS APC rate,426.55,32.15,,341.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1167.54,88,,934.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,439.29,33.11,,351.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,426.55,1194.08,
CARDIOVERSION,16015,CDM,480,RC,92960,HCPCS,Outpatient,,,1326.75,796.05,,1127.74,85,,902.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,426.55,32.15,,341.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1061.8,80.03,,849.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,563.84,102,,,fee schedule,Pays at 102% of CMS APC rate,1194.08,90,,955.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,426.55,32.15,,341.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,563.84,100,,,fee schedule,Pays at 100% of CMS APC rate,426.55,32.15,,341.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1167.54,88,,934.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,439.29,33.11,,351.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,426.55,1194.08,
INFASURF (CALFACTANT) 6ML VIAL,293420,CDM,250,RC,,,Outpatient,,,1343,805.8,,1141.55,85,,913.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,431.77,32.15,,345.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1074.8,80.03,,859.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1208.7,90,,966.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,431.77,32.15,,345.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,431.77,32.15,,345.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1181.84,88,,945.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,444.67,33.11,,355.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,431.77,1208.7,
INFASURF (CALFACTANT) 3ML VIAL,300898,CDM,250,RC,,,Outpatient,,,1343,805.8,,1141.55,85,,913.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,431.77,32.15,,345.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1074.8,80.03,,859.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1208.7,90,,966.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,431.77,32.15,,345.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,431.77,32.15,,345.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1181.84,88,,945.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,444.67,33.11,,355.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,431.77,1208.7,
"Emergency department visit, problem with significant threat to life or function",14009,CDM,450,RC,99285,HCPCS,Outpatient,,,1347.5,808.5,,1145.38,85,,916.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1078.4,80.03,,862.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,525.47,102,,,fee schedule,Pays at 102% of CMS APC rate,1212.75,90,,970.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,525.47,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1185.8,88,,948.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385,1212.75,
APP LOW COST SKIN SUB GRAFT 1ST 25CM,8415271,CDM,761,RC,15271,HCPCS,Outpatient,,,1355,813,,1151.75,85,,921.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1084.41,80.03,,867.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,1219.5,90,,975.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1192.4,88,,953.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,448.64,33.11,,358.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,435.63,1219.5,
APP LOW COST SKIN SUB GRAFT ADD 25CM,8415275,CDM,761,RC,15275,HCPCS,Outpatient,,,1355,813,,1151.75,85,,921.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1084.41,80.03,,867.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,1219.5,90,,975.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1192.4,88,,953.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,448.64,33.11,,358.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,435.63,1219.5,
APP LOW COST SKIN SUB GRAFT 1ST 100 CM,8415277,CDM,761,RC,15277,HCPCS,Outpatient,,,1355,813,,1151.75,85,,921.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1084.41,80.03,,867.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,1219.5,90,,975.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,435.63,32.15,,348.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1192.4,88,,953.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,448.64,33.11,,358.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,435.63,1219.5,
GRANULES TCP 5CC,4980091,CDM,270,RC,,,Outpatient,,,1355.5,813.3,,1152.18,85,,921.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,435.79,32.15,,348.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1084.81,80.03,,867.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1219.95,90,,975.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,435.79,32.15,,348.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,435.79,32.15,,348.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1192.84,88,,954.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,448.81,33.11,,359.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,435.79,1219.95,
EPIFIX 4 SQUARE CM,49791,CDM,270,RC,,,Outpatient,,,1360,816,,1156,85,,924.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,437.24,32.15,,349.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1088.41,80.03,,870.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1224,90,,979.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,437.24,32.15,,349.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,437.24,32.15,,349.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1196.8,88,,957.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,450.3,33.11,,360.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,437.24,1224,
GI PANEL PATHOGEN PCR (MAYO),1884895,CDM,300,RC,0097U,HCPCS,Outpatient,,,1361.4,816.84,,1157.19,85,,925.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,437.69,32.15,,350.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1089.53,80.03,,871.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1225.26,90,,980.21,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,437.69,32.15,,350.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,437.69,32.15,,350.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1198.03,88,,958.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,450.76,33.11,,360.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,437.69,1225.26,
"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",24123,CDM,483,RC,93306,HCPCS,Outpatient,,,1363.46,818.08,,1158.94,85,,927.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,438.35,32.15,,350.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1091.18,80.03,,872.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.34,102,,,fee schedule,Pays at 102% of CMS APC rate,1227.11,90,,981.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,438.35,32.15,,350.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.34,100,,,fee schedule,Pays at 100% of CMS APC rate,438.35,32.15,,350.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1199.84,88,,959.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,451.44,33.11,,361.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,438.35,1227.11,
NM VENOUS THROMBOSIS BILAT,2378458,CDM,341,RC,78458,HCPCS,Outpatient,,,1363.5,818.1,,1158.98,85,,927.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,438.37,32.15,,350.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1091.21,80.03,,872.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1227.15,90,,981.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,438.37,32.15,,350.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,438.37,32.15,,350.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1199.88,88,,959.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,451.45,33.11,,361.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,438.37,1227.15,
DELIVERY SERVICES,6005,CDM,722,RC,,,Outpatient,,,1380.63,828.38,,1173.54,85,,938.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,443.87,32.15,,355.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1104.92,80.03,,883.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1242.57,90,,994.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,443.87,32.15,,355.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,443.87,32.15,,355.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1214.95,88,,971.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.13,33.11,,365.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,443.87,1242.57,
PROCTOSIGMOIDOSCOPY,1445300,CDM,450,RC,45300,HCPCS,Outpatient,,,1381.75,829.05,,1174.49,85,,939.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1105.81,80.03,,884.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,796.71,102,,,fee schedule,Pays at 102% of CMS APC rate,1243.58,90,,994.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.71,100,,,fee schedule,Pays at 100% of CMS APC rate,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1215.94,88,,972.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.5,33.11,,366,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.23,1243.58,
I & D PERIANAL ABSCESS,1446050,CDM,450,RC,46050,HCPCS,Outpatient,,,1381.75,829.05,,1174.49,85,,939.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1105.81,80.03,,884.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,796.71,102,,,fee schedule,Pays at 102% of CMS APC rate,1243.58,90,,994.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.71,100,,,fee schedule,Pays at 100% of CMS APC rate,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1215.94,88,,972.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.5,33.11,,366,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.23,1243.58,
LIGATION OF HEMORRHOIDS,1446221,CDM,450,RC,46221,HCPCS,Outpatient,,,1381.75,829.05,,1174.49,85,,939.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1105.81,80.03,,884.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,796.71,102,,,fee schedule,Pays at 102% of CMS APC rate,1243.58,90,,994.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.71,100,,,fee schedule,Pays at 100% of CMS APC rate,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1215.94,88,,972.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.5,33.11,,366,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.23,1243.58,
ANOSCOPY W/ FB REMOVAL,1446608,CDM,450,RC,46608,HCPCS,Outpatient,,,1381.75,829.05,,1174.49,85,,939.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1105.81,80.03,,884.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,796.71,102,,,fee schedule,Pays at 102% of CMS APC rate,1243.58,90,,994.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.71,100,,,fee schedule,Pays at 100% of CMS APC rate,444.23,32.15,,355.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1215.94,88,,972.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.5,33.11,,366,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.23,1243.58,
UROLOGY EACH ADD 15 MIN,110014,CDM,360,RC,,,Outpatient,,,1381.95,829.17,,1174.66,85,,939.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.3,32.15,,355.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1105.97,80.03,,884.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1243.76,90,,995.01,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.3,32.15,,355.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,444.3,32.15,,355.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1216.12,88,,972.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.56,33.11,,366.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.3,1243.76,
MRI of chest and spine without dye,27010,CDM,610,RC,72146,HCPCS,Outpatient,,,1382.75,829.65,,1175.34,85,,940.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.55,32.15,,355.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1106.61,80.03,,885.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1244.48,90,,995.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.55,32.15,,355.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,444.55,32.15,,355.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1216.82,88,,973.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.83,33.11,,366.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.55,1244.48,
MRI of upper extremity without dye,27015,CDM,610,RC,73221,HCPCS,Outpatient,,,1382.75,829.65,,1175.34,85,,940.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.55,32.15,,355.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1106.61,80.03,,885.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1244.48,90,,995.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.55,32.15,,355.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,444.55,32.15,,355.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1216.82,88,,973.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,457.83,33.11,,366.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.55,1244.48,
NM CARDIAC BLOOD POOL IMAGING,2378472,CDM,341,RC,78472,HCPCS,Outpatient,,,1383.5,830.1,,1175.98,85,,940.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.8,32.15,,355.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1107.22,80.03,,885.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1245.15,90,,996.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.8,32.15,,355.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,444.8,32.15,,355.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1217.48,88,,973.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,458.08,33.11,,366.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.8,1245.15,
NM MUGA RESTING,23042,CDM,341,RC,78472,HCPCS,Outpatient,,,1394,836.4,,1184.9,85,,947.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,448.17,32.15,,358.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1115.62,80.03,,892.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1254.6,90,,1003.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,448.17,32.15,,358.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,448.17,32.15,,358.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1226.72,88,,981.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,461.55,33.11,,369.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,448.17,1254.6,
COMPREHENSIVE EXAM,2188309,CDM,310,RC,88309,HCPCS,Outpatient,,,1399.25,839.55,,1189.36,85,,951.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,187.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1119.82,80.03,,895.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,1259.33,90,,1007.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,187.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,187.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1231.34,88,,985.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,193.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,187.78,1259.33,
TOUCH PREP,2188333,CDM,310,RC,88333,HCPCS,Outpatient,,,1399.25,839.55,,1189.36,85,,951.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1119.82,80.03,,895.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,1259.33,90,,1007.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1231.34,88,,985.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,75.49,1259.33,
OR NERVE BLOCK ONLY,964450,CDM,360,RC,64450,HCPCS,Outpatient,,,1405.5,843.3,,1194.68,85,,955.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,451.87,32.15,,361.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1124.82,80.03,,899.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,1264.95,90,,1011.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,451.87,32.15,,361.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,451.87,32.15,,361.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1236.84,88,,989.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,465.36,33.11,,372.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,451.87,1264.95,
NERVE BLOCK ONLY,1464450,CDM,450,RC,64450,HCPCS,Outpatient,,,1405.5,843.3,,1194.68,85,,955.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,451.87,32.15,,361.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1124.82,80.03,,899.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,1264.95,90,,1011.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,451.87,32.15,,361.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,451.87,32.15,,361.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1236.84,88,,989.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,465.36,33.11,,372.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,451.87,1264.95,
NM LUNG SCAN VENT & PERFUSION,23011,CDM,341,RC,78582,HCPCS,Outpatient,,,1406.5,843.9,,1195.53,85,,956.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,452.19,32.15,,361.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1125.62,80.03,,900.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1265.85,90,,1012.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,452.19,32.15,,361.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,452.19,32.15,,361.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1237.72,88,,990.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,465.69,33.11,,372.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,452.19,1265.85,
NM SENTINEL NODE LYMPHOSCINTOGRAPHY,2378199,CDM,341,RC,78195,HCPCS,Outpatient,,,1406.5,843.9,,1195.53,85,,956.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,452.19,32.15,,361.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1125.62,80.03,,900.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1265.85,90,,1012.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,452.19,32.15,,361.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,452.19,32.15,,361.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1237.72,88,,990.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,465.69,33.11,,372.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,452.19,1265.85,
SWAN GANTZ DAILY CHG,497551,CDM,270,RC,,,Outpatient,,,1413,847.8,,1201.05,85,,960.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,454.28,32.15,,363.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1130.82,80.03,,904.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1271.7,90,,1017.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,454.28,32.15,,363.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,454.28,32.15,,363.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1243.44,88,,994.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,467.84,33.11,,374.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,454.28,1271.7,
SWAN GANZ MTR DAILY CHG,16002,CDM,731,RC,93231,HCPCS,Outpatient,,,1413,847.8,,1201.05,85,,960.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,454.28,32.15,,363.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1130.82,80.03,,904.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1271.7,90,,1017.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,454.28,32.15,,363.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,454.28,32.15,,363.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1243.44,88,,994.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,467.84,33.11,,374.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,454.28,1271.7,
THORACENTESIS,1432000,CDM,450,RC,32554,HCPCS,Outpatient,,,1416,849.6,,1203.6,85,,962.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1133.22,80.03,,906.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,1274.4,90,,1019.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.08,88,,996.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,468.84,33.11,,375.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.24,1274.4,
THORACENTESIS-PNEUMOTHORAX,1432002,CDM,450,RC,32554,HCPCS,Outpatient,,,1416,849.6,,1203.6,85,,962.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1133.22,80.03,,906.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,1274.4,90,,1019.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.08,88,,996.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,468.84,33.11,,375.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.24,1274.4,
PERICARDIOCENTESIS,1433010,CDM,450,RC,33016,HCPCS,Outpatient,,,1416,849.6,,1203.6,85,,962.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1133.22,80.03,,906.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,1274.4,90,,1019.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.08,88,,996.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,468.84,33.11,,375.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.24,1274.4,
CENTRAL VENOUS CATHETER PERCUTANEOUS <2,1436488,CDM,450,RC,36555,HCPCS,Outpatient,,,1416,849.6,,1203.6,85,,962.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1133.22,80.03,,906.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,1274.4,90,,1019.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.08,88,,996.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,468.84,33.11,,375.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.24,1274.4,
CENTRAL VENOUS CATH CUTDOWN < 2YO,1436490,CDM,450,RC,36555,HCPCS,Outpatient,,,1416,849.6,,1203.6,85,,962.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1133.22,80.03,,906.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,1274.4,90,,1019.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.08,88,,996.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,468.84,33.11,,375.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.24,1274.4,
CVC PERCUTANEOUS BY CUTDOWN > 2YO,1436491,CDM,450,RC,36556,HCPCS,Outpatient,,,1416,849.6,,1203.6,85,,962.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1133.22,80.03,,906.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,1274.4,90,,1019.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,455.24,32.15,,364.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.08,88,,996.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,468.84,33.11,,375.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.24,1274.4,
MRI of pelvis before and after dye,27022,CDM,610,RC,72197,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI of chest and spine with and without dye,27025,CDM,610,RC,72157,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI of neck/spine with and without dye,27026,CDM,610,RC,72156,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI EXT LOW NON-JNT WWO CONTRAST,27029,CDM,610,RC,73720,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI of abdomen without and with dye,27048,CDM,610,RC,74183,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI of abdomen without and with dye,27050,CDM,610,RC,74183,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI scan of brain before and after contrast,27053,CDM,610,RC,70553,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI EXT UP JOINT WWO CONTRAST RT,27057,CDM,610,RC,73223,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI of abdomen without and with dye,27091,CDM,610,RC,74183,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI scan of brain before and after contrast,27098,CDM,610,RC,70553,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI of lower extremity joint (knee/ankle) with and without dye,27017,CDM,614,RC,73723,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI EXT LOW NON-JNT WWO CONTRAST,27067,CDM,614,RC,73720,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI FORE FOOT - W WO CONTRAST RT,27620,CDM,614,RC,73720,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI FORE FOOT - W WO CONTRAST LT,27720,CDM,614,RC,73720,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
MRI of lower extremity joint (knee/ankle) with and without dye,27723,CDM,614,RC,73723,HCPCS,Outpatient,,,1417,850.2,,1204.45,85,,963.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.03,80.03,,907.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1275.3,90,,1020.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,455.57,32.15,,364.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1246.96,88,,997.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.17,33.11,,375.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.57,1275.3,
NM RENAL FLOW W/ PHARMACOLOGIC,23033,CDM,341,RC,78708,HCPCS,Outpatient,,,1419,851.4,,1206.15,85,,964.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1135.63,80.03,,908.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1277.1,90,,1021.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1248.72,88,,998.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.83,33.11,,375.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,456.21,1277.1,
NM LUNG PERF/VENT AEROSOL,23039,CDM,341,RC,78582,HCPCS,Outpatient,,,1419,851.4,,1206.15,85,,964.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1135.63,80.03,,908.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1277.1,90,,1021.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1248.72,88,,998.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.83,33.11,,375.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,456.21,1277.1,
NM LUNG PERF/VENT XENON,23040,CDM,341,RC,78598,HCPCS,Outpatient,,,1419,851.4,,1206.15,85,,964.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1135.63,80.03,,908.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1277.1,90,,1021.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,456.21,32.15,,364.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1248.72,88,,998.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.83,33.11,,375.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,456.21,1277.1,
NM BILIARY SCAN (GB),23006,CDM,341,RC,78226,HCPCS,Outpatient,,,1423.5,854.1,,1209.98,85,,967.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,457.66,32.15,,366.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1139.23,80.03,,911.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1281.15,90,,1024.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,457.66,32.15,,366.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,457.66,32.15,,366.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1252.68,88,,1002.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.32,33.11,,377.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,457.66,1281.15,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",23022,CDM,341,RC,78306,HCPCS,Outpatient,,,1423.5,854.1,,1209.98,85,,967.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,457.66,32.15,,366.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1139.23,80.03,,911.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1281.15,90,,1024.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,457.66,32.15,,366.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,457.66,32.15,,366.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1252.68,88,,1002.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.32,33.11,,377.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,457.66,1281.15,
HEPATITIS B IMMUNE GLOBULIN 5ML,293457,CDM,636,RC,J1573,HCPCS,Outpatient,,,1425,855,,1211.25,85,,969,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.14,32.15,,366.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.43,80.03,,912.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,63.4,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.5,90,,1026,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.14,32.15,,366.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.4,100,,,fee schedule,Pays at 100% of CMS APC rate,458.14,32.15,,366.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254,88,,1003.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.82,33.11,,377.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.14,1282.5,
THORACIC-LUMB-SACRAL ORTHO-CALM SHELL BR,31407,CDM,270,RC,L0482,HCPCS,Outpatient,,,1425.08,855.05,,1211.32,85,,969.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.16,32.15,,366.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.49,80.03,,912.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1282.57,90,,1026.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.16,32.15,,366.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,458.16,32.15,,366.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.07,88,,1003.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.84,33.11,,377.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.16,1282.57,
CT HEAD W CONTRAST,26002,CDM,351,RC,70460,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT scan head or brain without dye,26031,CDM,351,RC,70450,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT HEAD W/CONTRAST,26032,CDM,351,RC,70460,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT ORBITS W/O CONTRAST,26034,CDM,351,RC,70480,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT ORBITS W/CONTRAST,26035,CDM,351,RC,70481,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT Scan of the face and jaw without dye,26037,CDM,351,RC,70486,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT scan of neck with dye,26040,CDM,351,RC,70491,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT Scan of the face and jaw without dye,26063,CDM,351,RC,70486,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT TEMPORAL BONE W CONTRAST,26064,CDM,351,RC,70481,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT MASTOIDS WO CONTRAST,26066,CDM,351,RC,70480,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT Scan of the face and jaw without dye,26072,CDM,351,RC,70486,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT CHEST WWO CONTRAST,26013,CDM,352,RC,71270,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT scan of the thorax without dye,26041,CDM,352,RC,71250,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT scan of the thorax with dye,26042,CDM,352,RC,71260,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT SPINE CERVICAL W/O CONTRAST,26044,CDM,352,RC,72125,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT SPINE CERVICAL W/CONTRAST,26045,CDM,352,RC,72126,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT SPINE THORACIC W/O CONTRAST,26046,CDM,352,RC,72128,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT SPINE THORACIC W/CONTRAST,26047,CDM,352,RC,72129,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT scan of lower spine without dye,26048,CDM,352,RC,72131,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT SPINE LUMBAR W/CONTRAST,26049,CDM,352,RC,72132,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT of pelvis without dye,26050,CDM,352,RC,72192,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT EXTREMITY UPPER W/O CONTRAST,26051,CDM,352,RC,73200,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT EXTREMITY UPPER WITH CONTRAST,26052,CDM,352,RC,73201,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
"CT scan, pelvis, with contrast",26053,CDM,352,RC,72193,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT scan of leg without dye,26054,CDM,352,RC,73700,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
(E) CT EXTREMITY LOWER W/CONTRAST,26055,CDM,352,RC,73701,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT of abdomen without dye,26057,CDM,352,RC,74150,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT of abdomen with dye,26058,CDM,352,RC,74160,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT CERVICAL WWO CONTRAST,26073,CDM,352,RC,72127,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT BONE BX DEEP,26075,CDM,352,RC,20225,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT BONE BX SUPERFICIAL,26076,CDM,352,RC,20220,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,26086,CDM,352,RC,71275,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,26087,CDM,352,RC,71275,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CTA PELVIS,26095,CDM,352,RC,72191,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CTA UPPER EXT LT,26096,CDM,352,RC,73206,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CTA LOWER EXTREM LT,26097,CDM,352,RC,73706,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CTA LOWER EXTREM RT,26108,CDM,352,RC,73706,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CTA UPPER EXT RT,26109,CDM,352,RC,73206,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT THORACIC WWO CONTRAST,26114,CDM,352,RC,72130,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
CT LUMBAR W AND  W/O  CONTRAST,26151,CDM,352,RC,72133,HCPCS,Outpatient,,,1425.25,855.15,,1211.46,85,,969.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1140.63,80.03,,912.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1282.73,90,,1026.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,458.22,32.15,,366.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1254.22,88,,1003.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,471.9,33.11,,377.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,458.22,1282.73,
US BREAST BIOPSY,24130,CDM,320,RC,19125,HCPCS,Outpatient,,,1438.75,863.25,,1222.94,85,,978.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1151.43,80.03,,921.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3295.83,102,,,fee schedule,Pays at 102% of CMS APC rate,1294.88,90,,1035.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3295.83,100,,,fee schedule,Pays at 100% of CMS APC rate,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1266.1,88,,1012.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,476.37,33.11,,381.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,462.56,1294.88,
CT EXTREM UP W/WO CONTRAST RT,26023,CDM,352,RC,73202,HCPCS,Outpatient,,,1438.75,863.25,,1222.94,85,,978.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1151.43,80.03,,921.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1294.88,90,,1035.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1266.1,88,,1012.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,476.37,33.11,,381.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,462.56,1294.88,
CT EXTREM UP W/WO CONTRAST LT,26056,CDM,352,RC,73202,HCPCS,Outpatient,,,1438.75,863.25,,1222.94,85,,978.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1151.43,80.03,,921.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1294.88,90,,1035.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1266.1,88,,1012.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,476.37,33.11,,381.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,462.56,1294.88,
CT scan of leg without dye,26113,CDM,352,RC,73700,HCPCS,Outpatient,,,1438.75,863.25,,1222.94,85,,978.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1151.43,80.03,,921.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1294.88,90,,1035.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,462.56,32.15,,370.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1266.1,88,,1012.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,476.37,33.11,,381.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,462.56,1294.88,
BOTOX (botulinum type A) 100units,293118,CDM,636,RC,J0585,HCPCS,Outpatient,,,1442,865.2,,1225.7,85,,980.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1154.03,80.03,,923.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1297.8,90,,1038.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.45,100,,,fee schedule,Pays at 100% of CMS APC rate,6.33,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1268.96,88,,1015.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.52,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.33,1297.8,
CT of abdomen and pelvis without dye,26152,CDM,352,RC,74176,HCPCS,Outpatient,,,1442.75,865.65,,1226.34,85,,981.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1154.63,80.03,,923.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1298.48,90,,1038.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1269.62,88,,1015.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,477.69,33.11,,382.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,463.84,1298.48,
CT of abdomen and pelvis without dye,26157,CDM,352,RC,74176,HCPCS,Outpatient,,,1442.75,865.65,,1226.34,85,,981.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1154.63,80.03,,923.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1298.48,90,,1038.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1269.62,88,,1015.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,477.69,33.11,,382.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,463.84,1298.48,
MRI of leg without dye,27063,CDM,610,RC,73718,HCPCS,Outpatient,,,1442.75,865.65,,1226.34,85,,981.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1154.63,80.03,,923.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1298.48,90,,1038.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1269.62,88,,1015.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,477.69,33.11,,382.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,463.84,1298.48,
MRI of leg without dye,27064,CDM,610,RC,73718,HCPCS,Outpatient,,,1442.75,865.65,,1226.34,85,,981.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1154.63,80.03,,923.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1298.48,90,,1038.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,463.84,32.15,,371.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1269.62,88,,1015.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,477.69,33.11,,382.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,463.84,1298.48,
NM LIVER/SPLEEN IMAGING W/VASCULAR FLOW,2378216,CDM,341,RC,78216,HCPCS,Outpatient,,,1443.5,866.1,,1226.98,85,,981.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,464.09,32.15,,371.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1155.23,80.03,,924.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1299.15,90,,1039.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,464.09,32.15,,371.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,464.09,32.15,,371.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1270.28,88,,1016.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,477.94,33.11,,382.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,464.09,1299.15,
NM GI BLEED,23049,CDM,341,RC,78278,HCPCS,Outpatient,,,1447,868.2,,1229.95,85,,983.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,465.21,32.15,,372.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1158.03,80.03,,926.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1302.3,90,,1041.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,465.21,32.15,,372.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,465.21,32.15,,372.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1273.36,88,,1018.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,479.1,33.11,,383.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,465.21,1302.3,
PARACENTESIS INIT PERITON LAVAGE,1449080,CDM,450,RC,49084,HCPCS,Outpatient,,,1448,868.8,,1230.8,85,,984.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,465.53,32.15,,372.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1158.83,80.03,,927.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,791.41,102,,,fee schedule,Pays at 102% of CMS APC rate,1303.2,90,,1042.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,465.53,32.15,,372.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,791.41,100,,,fee schedule,Pays at 100% of CMS APC rate,465.53,32.15,,372.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1274.24,88,,1019.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,479.43,33.11,,383.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,465.53,1303.2,
TRUCLEAR SYSTEM RENTAL,4999943,CDM,272,RC,,,Outpatient,,,1455.5,873.3,,1237.18,85,,989.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,467.94,32.15,,374.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1164.84,80.03,,931.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1309.95,90,,1047.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,467.94,32.15,,374.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1455.5,,,,Other,Not Separately reimbursable,467.94,32.15,,374.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1280.84,88,,1024.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,481.92,33.11,,385.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,467.94,1309.95,
LEVEL 2 UROLOGY AND RELATED SERVICES,9220,CDM,790,RC,,,Outpatient,,,1463.5,878.1,,1243.98,85,,995.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,470.52,32.15,,376.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1171.24,80.03,,936.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1317.15,90,,1053.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,470.52,32.15,,376.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.5,,,,Other,Not Separately reimbursable,470.52,32.15,,376.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1287.88,88,,1030.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,484.56,33.11,,387.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,470.52,1317.15,
HYPERBARIC O2 PER SESSION,99183,CDM,413,RC,99183,HCPCS,Outpatient,,,1468,880.8,,1247.8,85,,998.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,471.96,32.15,,377.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1174.84,80.03,,939.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1321.2,90,,1056.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,471.96,32.15,,377.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1468,,,,Other,Not Separately reimbursable,471.96,32.15,,377.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1291.84,88,,1033.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,486.05,33.11,,388.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,471.96,1321.2,
CT CERVICAL WO CONTRAST,26014,CDM,352,RC,72125,HCPCS,Outpatient,,,1473,883.8,,1252.05,85,,1001.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,473.57,32.15,,378.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1178.84,80.03,,943.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1325.7,90,,1060.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,473.57,32.15,,378.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,473.57,32.15,,378.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1296.24,88,,1036.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,487.71,33.11,,390.17,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,473.57,1325.7,
YAG LASER,11001,CDM,270,RC,,,Outpatient,,,1473.5,884.1,,1252.48,85,,1001.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,473.73,32.15,,378.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1179.24,80.03,,943.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1326.15,90,,1060.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,473.73,32.15,,378.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1473.5,,,,Other,Not Separately reimbursable,473.73,32.15,,378.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1296.68,88,,1037.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,487.88,33.11,,390.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,473.73,1326.15,
Complete bilateral study of the extremities,24096,CDM,921,RC,93970,HCPCS,Outpatient,,,1473.5,884.1,,1252.48,85,,1001.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,473.73,32.15,,378.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1179.24,80.03,,943.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1326.15,90,,1060.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,473.73,32.15,,378.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,473.73,32.15,,378.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1296.68,88,,1037.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,487.88,33.11,,390.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,473.73,1326.15,
EPIFIX 2 X 3,49792,CDM,270,RC,,,Outpatient,,,1480,888,,1258,85,,1006.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,475.82,32.15,,380.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1184.44,80.03,,947.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1332,90,,1065.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,475.82,32.15,,380.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1480,,,,Other,Not Separately reimbursable,475.82,32.15,,380.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1302.4,88,,1041.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,490.03,33.11,,392.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,475.82,1332,
"FLUORO, FINE NEEDLE ASPIRATION,1ST LES",10007,CDM,320,RC,10007,HCPCS,Outpatient,,,1482,889.2,,1259.7,85,,1007.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1186.04,80.03,,948.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1333.8,90,,1067.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1304.16,88,,1043.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,490.69,33.11,,392.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,476.46,1333.8,
MM DIGITAL  MAMMO NEEDLE LOC,22123,CDM,401,RC,19125,HCPCS,Outpatient,,,1482,889.2,,1259.7,85,,1007.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1186.04,80.03,,948.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3295.83,102,,,fee schedule,Pays at 102% of CMS APC rate,1333.8,90,,1067.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3295.83,100,,,fee schedule,Pays at 100% of CMS APC rate,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1304.16,88,,1043.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,490.69,33.11,,392.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,476.46,1333.8,
US THYROID BIOPSY,24004,CDM,402,RC,10022,HCPCS,Outpatient,,,1482,889.2,,1259.7,85,,1007.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1186.04,80.03,,948.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1333.8,90,,1067.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1482,,,,Other,Not Separately reimbursable,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1304.16,88,,1043.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,490.69,33.11,,392.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,476.46,1333.8,
"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",24115,CDM,402,RC,10005,HCPCS,Outpatient,,,1482,889.2,,1259.7,85,,1007.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1186.04,80.03,,948.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1333.8,90,,1067.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1304.16,88,,1043.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,490.69,33.11,,392.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,476.46,1333.8,
EXCISION MALIGNANT LESION,8411603,CDM,450,RC,11603,HCPCS,Outpatient,,,1482,889.2,,1259.7,85,,1007.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1186.04,80.03,,948.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1333.8,90,,1067.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1304.16,88,,1043.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,490.69,33.11,,392.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,476.46,1333.8,
LEVEL 1 EXCISION/BIOPSY/INCIS & DRAINAGE,9130,CDM,790,RC,,,Outpatient,,,1482,889.2,,1259.7,85,,1007.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1186.04,80.03,,948.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1333.8,90,,1067.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1482,,,,Other,Not Separately reimbursable,476.46,32.15,,381.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1304.16,88,,1043.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,490.69,33.11,,392.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,476.46,1333.8,
(E) NM BILLIARY SCAN (GB),23029,CDM,341,RC,78226,HCPCS,Outpatient,,,1493.25,895.95,,1269.26,85,,1015.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1195.05,80.03,,956.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1343.93,90,,1075.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1314.06,88,,1051.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,494.42,33.11,,395.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,480.08,1343.93,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",23030,CDM,341,RC,78306,HCPCS,Outpatient,,,1493.25,895.95,,1269.26,85,,1015.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1195.05,80.03,,956.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1343.93,90,,1075.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1314.06,88,,1051.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,494.42,33.11,,395.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,480.08,1343.93,
PORT US EXTREMITY BILAT VASCULAR,24052,CDM,921,RC,93925,HCPCS,Outpatient,,,1493.25,895.95,,1269.26,85,,1015.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1195.05,80.03,,956.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1343.93,90,,1075.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,480.08,32.15,,384.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1314.06,88,,1051.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,494.42,33.11,,395.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,480.08,1343.93,
VEKLURY (remdesivir) 100MG INJ,302835,CDM,250,RC,J3490,HCPCS,Outpatient,,,1497.6,898.56,,1272.96,85,,1018.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,481.48,32.15,,385.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1198.53,80.03,,958.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1347.84,90,,1078.27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,481.48,32.15,,385.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1497.6,,,,Other,Not Separately reimbursable,481.48,32.15,,385.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1317.89,88,,1054.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,495.86,33.11,,396.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,481.48,1347.84,
COLONOSCOPY,9020,CDM,750,RC,,,Outpatient,,,1499.75,899.85,,1274.79,85,,1019.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,482.17,32.15,,385.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1200.25,80.03,,960.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1349.78,90,,1079.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,482.17,32.15,,385.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1499.75,,,,Other,Not Separately reimbursable,482.17,32.15,,385.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1319.78,88,,1055.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,496.57,33.11,,397.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,482.17,1349.78,
NM CEREBRAL FLOW STUDY,23014,CDM,341,RC,78610,HCPCS,Outpatient,,,1503,901.8,,1277.55,85,,1022.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,483.21,32.15,,386.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1202.85,80.03,,962.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1352.7,90,,1082.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,483.21,32.15,,386.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,483.21,32.15,,386.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1322.64,88,,1058.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,497.64,33.11,,398.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,483.21,1352.7,
NM CARDIAC BLOOD POOL FIRST PASS TE,2378481,CDM,341,RC,78481,HCPCS,Outpatient,,,1503,901.8,,1277.55,85,,1022.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,483.21,32.15,,386.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1202.85,80.03,,962.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1352.7,90,,1082.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,483.21,32.15,,386.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,483.21,32.15,,386.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1322.64,88,,1058.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,497.64,33.11,,398.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,483.21,1352.7,
MASTECTOMY ADD 15 MIN,110021,CDM,360,RC,,,Outpatient,,,1503.63,902.18,,1278.09,85,,1022.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,483.42,32.15,,386.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1203.36,80.03,,962.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1353.27,90,,1082.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,483.42,32.15,,386.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1503.63,,,,Other,Not Separately reimbursable,483.42,32.15,,386.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1323.19,88,,1058.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,497.85,33.11,,398.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,483.42,1353.27,
NEUPOGEN (filgrastim) 480MCG INJ,293441,CDM,636,RC,J1442,HCPCS,Outpatient,,,1530.53,918.32,,1300.95,85,,1040.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,0.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1224.88,80.03,,979.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1,102,,,fee schedule,Pays at 102% of CMS APC rate,1377.48,90,,1101.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,0.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1,100,,,fee schedule,Pays at 100% of CMS APC rate,0.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1346.87,88,,1077.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,0.99,1377.48,
CIDOFOVIR 375MG /5ML VIAL,293868,CDM,636,RC,J0740,HCPCS,Outpatient,,,1533,919.8,,1303.05,85,,1042.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,492.86,32.15,,394.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1226.86,80.03,,981.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,561.38,102,,,fee schedule,Pays at 102% of CMS APC rate,1379.7,90,,1103.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,492.86,32.15,,394.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,561.38,100,,,fee schedule,Pays at 100% of CMS APC rate,492.86,32.15,,394.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1349.04,88,,1079.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,507.58,33.11,,406.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,492.86,1379.7,
NEEDLE URETEX TRANSOBTURATOR INTRODUCER,4999012,CDM,270,RC,,,Outpatient,,,1544,926.4,,1312.4,85,,1049.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,496.4,32.15,,397.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1235.66,80.03,,988.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1389.6,90,,1111.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,496.4,32.15,,397.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1544,,,,Other,Not Separately reimbursable,496.4,32.15,,397.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1358.72,88,,1086.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,511.22,33.11,,408.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,496.4,1389.6,
URETEX TRANSOBTURATOR,4999011,CDM,278,RC,C1771,HCPCS,Outpatient,,,1544,926.4,,1312.4,85,,1049.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,496.4,32.15,,397.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1235.66,80.03,,988.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1389.6,90,,1111.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,496.4,32.15,,397.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1544,,,,Other,Not Separately reimbursable,496.4,32.15,,397.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1358.72,88,,1086.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,511.22,33.11,,408.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,496.4,1389.6,
NM CARDIAC BLOOD POOL MULTI STUDIES,2378483,CDM,341,RC,78483,HCPCS,Outpatient,,,1553.25,931.95,,1320.26,85,,1056.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,499.37,32.15,,399.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1243.07,80.03,,994.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1397.93,90,,1118.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,499.37,32.15,,399.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,499.37,32.15,,399.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1366.86,88,,1093.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,514.28,33.11,,411.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,499.37,1397.93,
STIMULATOR TEST,4999930,CDM,270,RC,,,Outpatient,,,1583,949.8,,1345.55,85,,1076.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,508.93,32.15,,407.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1266.87,80.03,,1013.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1424.7,90,,1139.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,508.93,32.15,,407.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1583,,,,Other,Not Separately reimbursable,508.93,32.15,,407.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1393.04,88,,1114.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,524.13,33.11,,419.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,508.93,1424.7,
PICC CATH REMOVAL,4026,CDM,761,RC,36589,HCPCS,Outpatient,,,1584.5,950.7,,1346.83,85,,1077.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,509.42,32.15,,407.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1268.08,80.03,,1014.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.61,102,,,fee schedule,Pays at 102% of CMS APC rate,1426.05,90,,1140.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,509.42,32.15,,407.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.61,100,,,fee schedule,Pays at 100% of CMS APC rate,509.42,32.15,,407.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1394.36,88,,1115.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,524.63,33.11,,419.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,509.42,1426.05,
REMOVAL CORNEAL RUST RING,1465435,CDM,450,RC,65435,HCPCS,Outpatient,,,1602.25,961.35,,1361.91,85,,1089.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,515.12,32.15,,412.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1282.28,80.03,,1025.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,836.6,102,,,fee schedule,Pays at 102% of CMS APC rate,1442.03,90,,1153.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,515.12,32.15,,412.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,836.6,100,,,fee schedule,Pays at 100% of CMS APC rate,515.12,32.15,,412.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1409.98,88,,1127.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,530.5,33.11,,424.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,515.12,1442.03,
US THORACENTESIS WITH IMAGING GUIDANCE,2232555,CDM,761,RC,32555,HCPCS,Outpatient,,,1609.5,965.7,,1368.08,85,,1094.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,517.45,32.15,,413.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1288.08,80.03,,1030.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,1448.55,90,,1158.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,517.45,32.15,,413.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,517.45,32.15,,413.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1416.36,88,,1133.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,532.91,33.11,,426.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,517.45,1448.55,
(E) BONE SCAN THREE PHASE STUDY,23023,CDM,341,RC,78315,HCPCS,Outpatient,,,1623,973.8,,1379.55,85,,1103.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,521.79,32.15,,417.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1298.89,80.03,,1039.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1460.7,90,,1168.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,521.79,32.15,,417.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,521.79,32.15,,417.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1428.24,88,,1142.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,537.38,33.11,,429.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,521.79,1460.7,
LARYNGOSCOPY WITH BIOPSY,11004,CDM,761,RC,31525,HCPCS,Outpatient,,,1643.5,986.1,,1396.98,85,,1117.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,528.39,32.15,,422.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1315.29,80.03,,1052.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1532.54,102,,,fee schedule,Pays at 102% of CMS APC rate,1479.15,90,,1183.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,528.39,32.15,,422.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1532.54,100,,,fee schedule,Pays at 100% of CMS APC rate,528.39,32.15,,422.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1446.28,88,,1157.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,544.16,33.11,,435.33,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,528.39,1479.15,
BRONCHOSCOPY W/BIOPSY,9047,CDM,360,RC,,,Outpatient,,,1660.5,996.3,,1411.43,85,,1129.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,533.85,32.15,,427.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1328.9,80.03,,1063.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1494.45,90,,1195.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,533.85,32.15,,427.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1660.5,,,,Other,Not Separately reimbursable,533.85,32.15,,427.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1461.24,88,,1168.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,549.79,33.11,,439.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,533.85,1494.45,
NM GALLIUM TUMOR LOC,23018,CDM,341,RC,78801,HCPCS,Outpatient,,,1662.5,997.5,,1413.13,85,,1130.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.49,32.15,,427.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.5,80.03,,1064.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.25,90,,1197,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.49,32.15,,427.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,534.49,32.15,,427.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463,88,,1170.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.45,33.11,,440.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.49,1496.25,
MRI TEMPOROMANDIBULAR JOINT,27001,CDM,610,RC,70336,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of brain stem without dye,27003,CDM,610,RC,70551,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI BRAIN W CONTRAST,27004,CDM,610,RC,70552,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI CHEST W CONTRAST,27005,CDM,610,RC,71551,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI THORACIC W CONTRAST,27008,CDM,610,RC,72147,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI CERVICAL W CONTRAST,27012,CDM,610,RC,72142,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI PELVIS W CONTRAST,27013,CDM,610,RC,72196,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of leg without dye,27016,CDM,610,RC,73718,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI BONE MARROW,27020,CDM,610,RC,77084,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI EXT UP JOINT W CONTRAST LT,27034,CDM,610,RC,73222,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI BRACHIAL PLEXUS WO CONTRAST,27035,CDM,610,RC,70540,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI IACS W CONTRAST,27038,CDM,610,RC,70552,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI THYROID SOFT TISS WO CONTRAST,27040,CDM,610,RC,70540,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI THYROID SOFT TISSUE WITH CONTRAST,27041,CDM,610,RC,70542,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRA CAROTID WITH CONTRAST,27044,CDM,610,RC,70548,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI KIDNEY WITH CONTRAST,27046,CDM,610,RC,74182,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of abdomen without dye,27047,CDM,610,RC,74181,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI ABDOMEN WITH CONTRAST,27049,CDM,610,RC,74182,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of abdomen without dye,27052,CDM,610,RC,74181,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of upper extremity without dye,27056,CDM,610,RC,73221,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI EXT UP ANY-JNT W CONTRAST RT,27058,CDM,610,RC,73222,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI NECK SOFT TISSUE W/O CONTRAST,27068,CDM,610,RC,70540,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI OF BREAST WITHOUT UNILAT,27073,CDM,610,RC,77058,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1662.75,,,,Other,Not Separately reimbursable,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI OF BREAST WITH  UNILAT,27074,CDM,610,RC,77058,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1662.75,,,,Other,Not Separately reimbursable,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI CHEST WITHOUT  CONTRAST,27083,CDM,610,RC,71550,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI TMJ WITHOUT,27090,CDM,610,RC,70336,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of abdomen without dye,27097,CDM,610,RC,74181,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI FACE SINUS WITHOUT,27102,CDM,610,RC,70540,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI EXT UP ANY JNT W CONTRAST LT,27221,CDM,610,RC,73222,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of brain stem without dye,27224,CDM,610,RC,70551,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of the neck or spine without dye,27006,CDM,612,RC,72141,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI scan of lower spinal canal,27007,CDM,612,RC,72148,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of lower extremity joint (knee/ankle) with dye,27036,CDM,614,RC,73722,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of lower extremity joint (knee/ankle) with dye,27062,CDM,614,RC,73722,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI FORE FOOT - W CONTRAST RT,27619,CDM,614,RC,73719,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of lower extremity joint (knee/ankle) with dye,27622,CDM,614,RC,73722,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI FORE FOOT - W CONTRAST LT,27719,CDM,614,RC,73719,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
MRI of lower extremity joint (knee/ankle) with dye,27722,CDM,614,RC,73722,HCPCS,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
GASTROSCOPY W/BIOPSY,9023,CDM,750,RC,,,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1662.75,,,,Other,Not Separately reimbursable,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
GASTROSCOPY W/FORIEGN BODY REMOVAL,9024,CDM,750,RC,,,Outpatient,,,1662.75,997.65,,1413.34,85,,1130.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.7,80.03,,1064.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1496.48,90,,1197.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1662.75,,,,Other,Not Separately reimbursable,534.57,32.15,,427.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1463.22,88,,1170.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,550.54,33.11,,440.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,534.57,1496.48,
NM HIDA W/CCK,23046,CDM,341,RC,78227,HCPCS,Outpatient,,,1672.5,1003.5,,1421.63,85,,1137.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,537.71,32.15,,430.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1338.5,80.03,,1070.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1505.25,90,,1204.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,537.71,32.15,,430.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,537.71,32.15,,430.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1471.8,88,,1177.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,553.76,33.11,,443.01,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,537.71,1505.25,
NM LIMITED AREA WHITE BLOOD CELL IMAGING,2378805,CDM,341,RC,78805,HCPCS,Outpatient,,,1673,1003.8,,1422.05,85,,1137.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,537.87,32.15,,430.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1338.9,80.03,,1071.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1505.7,90,,1204.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,537.87,32.15,,430.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1673,,,,Other,Not Separately reimbursable,537.87,32.15,,430.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1472.24,88,,1177.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,553.93,33.11,,443.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,537.87,1505.7,
TET IMMUNE GLOBULIN (HYPERTET),296056,CDM,636,RC,J1670,HCPCS,Outpatient,,,1682.4,1009.44,,1430.04,85,,1144.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,584.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1346.42,80.03,,1077.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,596.07,102,,,fee schedule,Pays at 102% of CMS APC rate,1514.16,90,,1211.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,584.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,596.07,100,,,fee schedule,Pays at 100% of CMS APC rate,584.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1480.51,88,,1184.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,601.92,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,584.39,1514.16,
AMP 1ST 30 MIN,11005,CDM,360,RC,,,Outpatient,,,1687.5,1012.5,,1434.38,85,,1147.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,542.53,32.15,,434.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1350.51,80.03,,1080.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1518.75,90,,1215,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,542.53,32.15,,434.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1687.5,,,,Other,Not Separately reimbursable,542.53,32.15,,434.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1485,88,,1188,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,558.73,33.11,,446.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,542.53,1518.75,
ELECTRODE 5FR BALLOON PACING,49096,CDM,270,RC,,,Outpatient,,,1688.25,1012.95,,1435.01,85,,1148.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,542.77,32.15,,434.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1351.11,80.03,,1080.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1519.43,90,,1215.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,542.77,32.15,,434.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1688.25,,,,Other,Not Separately reimbursable,542.77,32.15,,434.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1485.66,88,,1188.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,558.98,33.11,,447.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,542.77,1519.43,
(E) LIVER AND SPLEEN IMAGING,23028,CDM,341,RC,78215,HCPCS,Outpatient,,,1691.75,1015.05,,1437.99,85,,1150.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,543.9,32.15,,435.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1353.91,80.03,,1083.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1522.58,90,,1218.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,543.9,32.15,,435.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,543.9,32.15,,435.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1488.74,88,,1190.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,560.14,33.11,,448.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,543.9,1522.58,
"MuSK AUTO ANTIBODY, SERUM",1883665,CDM,300,RC,83519,HCPCS,Outpatient,,,1700,1020,,1445,85,,1156,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1360.51,80.03,,1088.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,18.76,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,1530,90,,1224,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,18.76,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,16.99,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1496,88,,1196.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.5,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,16.99,1530,
ENDOSCOPIC RCP,9027,CDM,360,RC,,,Outpatient,,,1706.25,1023.75,,1450.31,85,,1160.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,548.56,32.15,,438.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1365.51,80.03,,1092.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1535.63,90,,1228.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,548.56,32.15,,438.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1706.25,,,,Other,Not Separately reimbursable,548.56,32.15,,438.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1501.5,88,,1201.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,564.94,33.11,,451.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,548.56,1535.63,
ARTHROSCOPY,9035,CDM,360,RC,,,Outpatient,,,1708.25,1024.95,,1452.01,85,,1161.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,549.2,32.15,,439.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1367.11,80.03,,1093.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1537.43,90,,1229.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,549.2,32.15,,439.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1708.25,,,,Other,Not Separately reimbursable,549.2,32.15,,439.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1503.26,88,,1202.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,565.6,33.11,,452.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,549.2,1537.43,
KIT TAPE ARIS,4980090,CDM,278,RC,,,Outpatient,,,1715.25,1029.15,,1457.96,85,,1166.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,551.45,32.15,,441.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1372.71,80.03,,1098.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1543.73,90,,1234.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,551.45,32.15,,441.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1715.25,,,,Other,Not Separately reimbursable,551.45,32.15,,441.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1509.42,88,,1207.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,567.92,33.11,,454.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,551.45,1543.73,
(E) URETERAL REFLUX STUDY W/VASC FLOW,2370002,CDM,341,RC,78740,HCPCS,Outpatient,,,1722,1033.2,,1463.7,85,,1170.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,553.62,32.15,,442.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1378.12,80.03,,1102.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1549.8,90,,1239.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,553.62,32.15,,442.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,553.62,32.15,,442.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1515.36,88,,1212.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,570.15,33.11,,456.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,553.62,1549.8,
VIRAZOLE 6GM VIAL,293210,CDM,250,RC,,,Outpatient,,,1725.25,1035.15,,1466.46,85,,1173.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,554.67,32.15,,443.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1380.72,80.03,,1104.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1552.73,90,,1242.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,554.67,32.15,,443.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1725.25,,,,Other,Not Separately reimbursable,554.67,32.15,,443.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1518.22,88,,1214.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,571.23,33.11,,456.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,554.67,1552.73,
SYSTEM SUPPORT URETEX 2 TRANSOBTURATOR,4999034,CDM,278,RC,C1771,HCPCS,Outpatient,,,1751,1050.6,,1488.35,85,,1190.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,562.95,32.15,,450.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1401.33,80.03,,1121.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1575.9,90,,1260.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,562.95,32.15,,450.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1751,,,,Other,Not Separately reimbursable,562.95,32.15,,450.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1540.88,88,,1232.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,579.76,33.11,,463.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,562.95,1575.9,
(E) HEPATOBILIARY DUCTAL SYSTEM IMAGING,23024,CDM,341,RC,78226,HCPCS,Outpatient,,,1753,1051.8,,1490.05,85,,1192.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,563.59,32.15,,450.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1402.93,80.03,,1122.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1577.7,90,,1262.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,563.59,32.15,,450.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,563.59,32.15,,450.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1542.64,88,,1234.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,580.42,33.11,,464.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,563.59,1577.7,
OB GYN ADD 15 MIN,110013,CDM,360,RC,,,Outpatient,,,1753.13,1051.88,,1490.16,85,,1192.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,563.63,32.15,,450.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1403.03,80.03,,1122.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1577.82,90,,1262.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,563.63,32.15,,450.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1753.13,,,,Other,Not Separately reimbursable,563.63,32.15,,450.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1542.75,88,,1234.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,580.46,33.11,,464.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,563.63,1577.82,
SECONDARY CLOSURE WOUND DEHIS EXTENSIVE,8413160,CDM,761,RC,13160,HCPCS,Outpatient,,,1758.24,1054.94,,1494.5,85,,1195.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,565.27,32.15,,452.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1407.12,80.03,,1125.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,1582.42,90,,1265.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,565.27,32.15,,452.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,565.27,32.15,,452.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1547.25,88,,1237.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,582.15,33.11,,465.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,565.27,1582.42,
MRI EXT UP JOINT W CONTRAST RT,27060,CDM,610,RC,73222,HCPCS,Outpatient,,,1764.75,1058.85,,1500.04,85,,1200.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,567.37,32.15,,453.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1412.33,80.03,,1129.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,1588.28,90,,1270.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,567.37,32.15,,453.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,567.37,32.15,,453.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1552.98,88,,1242.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,584.31,33.11,,467.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,567.37,1588.28,
MRA OF PELVIS WITH OR W/O CONTRAST,27079,CDM,610,RC,72198,HCPCS,Outpatient,,,1767,1060.2,,1501.95,85,,1201.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,568.09,32.15,,454.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1414.13,80.03,,1131.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1590.3,90,,1272.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,568.09,32.15,,454.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1767,,,,Other,Not Separately reimbursable,568.09,32.15,,454.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1554.96,88,,1243.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,585.05,33.11,,468.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,568.09,1590.3,
SYSTEM MGMT TISSUE SURGICAL 45CM,4999916,CDM,270,RC,,,Outpatient,,,1768.5,1061.1,,1503.23,85,,1202.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,568.57,32.15,,454.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1415.33,80.03,,1132.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1591.65,90,,1273.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,568.57,32.15,,454.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1768.5,,,,Other,Not Separately reimbursable,568.57,32.15,,454.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1556.28,88,,1245.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,585.55,33.11,,468.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,568.57,1591.65,
SYSTEM MGMT TISSUE SURGICAL 35MM,4999917,CDM,270,RC,,,Outpatient,,,1768.5,1061.1,,1503.23,85,,1202.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,568.57,32.15,,454.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1415.33,80.03,,1132.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1591.65,90,,1273.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,568.57,32.15,,454.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1768.5,,,,Other,Not Separately reimbursable,568.57,32.15,,454.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1556.28,88,,1245.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,585.55,33.11,,468.44,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,568.57,1591.65,
MRI scan of brain before and after contrast,27019,CDM,610,RC,70553,HCPCS,Outpatient,,,1771,1062.6,,1505.35,85,,1204.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,569.38,32.15,,455.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1417.33,80.03,,1133.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1593.9,90,,1275.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,569.38,32.15,,455.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,569.38,32.15,,455.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1558.48,88,,1246.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,586.38,33.11,,469.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,569.38,1593.9,
"US BRST BX W/WO CLIP, SPECM IMG, INC 1ST",19083,CDM,320,RC,19285,HCPCS,Outpatient,,,1775,1065,,1508.75,85,,1207,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,570.66,32.15,,456.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1420.53,80.03,,1136.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.16,102,,,fee schedule,Pays at 102% of CMS APC rate,1597.5,90,,1278,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,570.66,32.15,,456.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.16,100,,,fee schedule,Pays at 100% of CMS APC rate,570.66,32.15,,456.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1562,88,,1249.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,587.7,33.11,,470.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,570.66,1597.5,
MM BREAST LOCALIZATION PLACEMENT 1ST LES,19285,CDM,403,RC,19285,HCPCS,Outpatient,,,1775,1065,,1508.75,85,,1207,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,570.66,32.15,,456.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1420.53,80.03,,1136.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.16,102,,,fee schedule,Pays at 102% of CMS APC rate,1597.5,90,,1278,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,570.66,32.15,,456.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.16,100,,,fee schedule,Pays at 100% of CMS APC rate,570.66,32.15,,456.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1562,88,,1249.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,587.7,33.11,,470.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,570.66,1597.5,
NM WHOLE BODY WHITE CELL,2378806,CDM,340,RC,78806,HCPCS,Outpatient,,,1791.25,1074.75,,1522.56,85,,1218.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,575.89,32.15,,460.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1433.54,80.03,,1146.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1612.13,90,,1289.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,575.89,32.15,,460.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1791.25,,,,Other,Not Separately reimbursable,575.89,32.15,,460.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1576.3,88,,1261.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,593.08,33.11,,474.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,575.89,1612.13,
NM RADIONUCLIDE WHOLE BODY,2378802,CDM,341,RC,78802,HCPCS,Outpatient,,,1791.25,1074.75,,1522.56,85,,1218.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,575.89,32.15,,460.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1433.54,80.03,,1146.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1612.13,90,,1289.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,575.89,32.15,,460.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,575.89,32.15,,460.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1576.3,88,,1261.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,593.08,33.11,,474.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,575.89,1612.13,
"CIRCUMCISION, CLAMP OR OTHER DEVICE W LO",54150,CDM,360,RC,54150,HCPCS,Outpatient,,,1792.99,1075.79,,1524.04,85,,1219.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,576.45,32.15,,461.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1434.93,80.03,,1147.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1778.27,102,,,fee schedule,Pays at 102% of CMS APC rate,1613.69,90,,1290.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,576.45,32.15,,461.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1778.27,100,,,fee schedule,Pays at 100% of CMS APC rate,576.45,32.15,,461.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1577.83,88,,1262.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,593.66,33.11,,474.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,576.45,1613.69,
OVER 7.5 CM,1413300,CDM,450,RC,,,Outpatient,,,1798.75,1079.25,,1528.94,85,,1223.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,578.3,32.15,,462.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1439.54,80.03,,1151.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1618.88,90,,1295.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,578.3,32.15,,462.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1798.75,,,,Other,Not Separately reimbursable,578.3,32.15,,462.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1582.9,88,,1266.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,595.57,33.11,,476.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,578.3,1618.88,
MULTIPLE SLEEP LATENCY TEST,30301,CDM,410,RC,95805,HCPCS,Outpatient,,,1802,1081.2,,1531.7,85,,1225.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,579.34,32.15,,463.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1442.14,80.03,,1153.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,463.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1621.8,90,,1297.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,579.34,32.15,,463.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,463.45,100,,,fee schedule,Pays at 100% of CMS APC rate,579.34,32.15,,463.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1585.76,88,,1268.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,596.64,33.11,,477.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,579.34,1621.8,
LUPRON DEPOT (leuprolide) 11.25MG INJ*NF,293480,CDM,636,RC,J1950,HCPCS,Outpatient,,,1805.55,1083.33,,1534.72,85,,1227.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1444.98,80.03,,1155.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1554.82,102,,,fee schedule,Pays at 102% of CMS APC rate,1625,90,,1300,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1554.82,100,,,fee schedule,Pays at 100% of CMS APC rate,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1588.88,88,,1271.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1570.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1444.98,1625,
I & D ISCHIORECTAL AND/OR PERIRECTAL ABS,1446040,CDM,450,RC,46040,HCPCS,Outpatient,,,1816.5,1089.9,,1544.03,85,,1235.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,584,32.15,,467.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1453.74,80.03,,1162.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1038.18,102,,,fee schedule,Pays at 102% of CMS APC rate,1634.85,90,,1307.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,584,32.15,,467.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1038.18,100,,,fee schedule,Pays at 100% of CMS APC rate,584,32.15,,467.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1598.52,88,,1278.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,601.44,33.11,,481.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,584,1634.85,
ENUC/EXC THROMB. HEMORR,1446320,CDM,450,RC,46320,HCPCS,Outpatient,,,1816.5,1089.9,,1544.03,85,,1235.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,584,32.15,,467.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1453.74,80.03,,1162.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1038.18,102,,,fee schedule,Pays at 102% of CMS APC rate,1634.85,90,,1307.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,584,32.15,,467.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1038.18,100,,,fee schedule,Pays at 100% of CMS APC rate,584,32.15,,467.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1598.52,88,,1278.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,601.44,33.11,,481.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,584,1634.85,
NM RENAL SCAN,23015,CDM,341,RC,78700,HCPCS,Outpatient,,,1821.75,1093.05,,1548.49,85,,1238.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,585.69,32.15,,468.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1457.95,80.03,,1166.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1639.58,90,,1311.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,585.69,32.15,,468.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,585.69,32.15,,468.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1603.14,88,,1282.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,603.18,33.11,,482.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,585.69,1639.58,
KIT WRIST FIXATION RADIOLUCENT,4999013,CDM,270,RC,,,Outpatient,,,1845.5,1107.3,,1568.68,85,,1254.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,593.33,32.15,,474.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1476.95,80.03,,1181.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1660.95,90,,1328.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,593.33,32.15,,474.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1845.5,,,,Other,Not Separately reimbursable,593.33,32.15,,474.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1624.04,88,,1299.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,611.05,33.11,,488.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,593.33,1660.95,
MESENTERIC ANGIOGRAPHY,26101,CDM,352,RC,74175,HCPCS,Outpatient,,,1851.5,1110.9,,1573.78,85,,1259.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,595.26,32.15,,476.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1481.76,80.03,,1185.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1666.35,90,,1333.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,595.26,32.15,,476.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,595.26,32.15,,476.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1629.32,88,,1303.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,613.03,33.11,,490.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,595.26,1666.35,
SUPERFICIAL BONE BIOPSY - OPEN,20240,CDM,761,RC,20240,HCPCS,Outpatient,,,1863,1117.8,,1583.55,85,,1266.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,598.95,32.15,,479.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1490.96,80.03,,1192.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2476.56,102,,,fee schedule,Pays at 102% of CMS APC rate,1676.7,90,,1341.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,598.95,32.15,,479.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2476.56,100,,,fee schedule,Pays at 100% of CMS APC rate,598.95,32.15,,479.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1639.44,88,,1311.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,616.84,33.11,,493.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,598.95,1676.7,
1'ST 30 MINUTES O.R.,9005,CDM,360,RC,,,Outpatient,,,1874.69,1124.81,,1593.49,85,,1274.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,602.71,32.15,,482.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1500.31,80.03,,1200.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1687.22,90,,1349.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,602.71,32.15,,482.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1874.69,,,,Other,Not Separately reimbursable,602.71,32.15,,482.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1649.73,88,,1319.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,620.71,33.11,,496.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,602.71,1687.22,
MRI EXT LOW NON-JNT BILAT WWO CONTRAST,27030,CDM,614,RC,73720,HCPCS,Outpatient,,,1889,1133.4,,1605.65,85,,1284.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,607.31,32.15,,485.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1511.77,80.03,,1209.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1700.1,90,,1360.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,607.31,32.15,,485.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,607.31,32.15,,485.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1662.32,88,,1329.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,625.45,33.11,,500.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,607.31,1700.1,
ARGATROBAN 250MG/2.5ML INJ,293487,CDM,636,RC,C9121,HCPCS,Outpatient,,,1890,1134,,1606.5,85,,1285.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,607.64,32.15,,486.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1512.57,80.03,,1210.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1701,90,,1360.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,607.64,32.15,,486.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1890,,,,Other,Not Separately reimbursable,607.64,32.15,,486.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1663.2,88,,1330.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,625.78,33.11,,500.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,607.64,1701,
LEVEL 6 CRITICAL CARE ED,14010,CDM,450,RC,99291,HCPCS,Outpatient,,,1898.25,1138.95,,1613.51,85,,1290.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.29,32.15,,488.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1519.17,80.03,,1215.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,736.01,102,,,fee schedule,Pays at 102% of CMS APC rate,1708.43,90,,1366.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.29,32.15,,488.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,736.01,100,,,fee schedule,Pays at 100% of CMS APC rate,610.29,32.15,,488.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1670.46,88,,1336.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,628.51,33.11,,502.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.29,1708.43,
CRITICIAL CARE 1ST HR W PROC,14023,CDM,450,RC,99291,HCPCS,Outpatient,,,1898.25,1138.95,,1613.51,85,,1290.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.29,32.15,,488.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1519.17,80.03,,1215.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,736.01,102,,,fee schedule,Pays at 102% of CMS APC rate,1708.43,90,,1366.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.29,32.15,,488.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,736.01,100,,,fee schedule,Pays at 100% of CMS APC rate,610.29,32.15,,488.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1670.46,88,,1336.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,628.51,33.11,,502.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.29,1708.43,
ADD GASTRO PROCEDURE,110016,CDM,360,RC,,,Outpatient,,,1900,1140,,1615,85,,1292,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.85,32.15,,488.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.57,80.03,,1216.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1710,90,,1368,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.85,32.15,,488.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1900,,,,Other,Not Separately reimbursable,610.85,32.15,,488.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672,88,,1337.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.09,33.11,,503.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.85,1710,
CT HEAD WWO CONTRAST,26003,CDM,351,RC,70470,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
(E) CT HEAD W & W/O CONTRAST,26033,CDM,351,RC,70470,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
(E) CT ORBITS W & W/O CONTRAST,26036,CDM,351,RC,70482,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
(E) CT SOFT TISSUE NECK W/WO CONTRAST,26069,CDM,351,RC,70492,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
CT EXTREM LOW WWO CONTRAST LT,26026,CDM,352,RC,73702,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
CT of abdomen with and without dye,26059,CDM,352,RC,74170,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
CT PELVIS WWO CONTRAST,26067,CDM,352,RC,72194,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
CT EXTREM LOW WWO CONTRAST RT,26105,CDM,352,RC,73702,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
CTA BILATERAL LOWER EXTREM,26112,CDM,352,RC,73706,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
CT T-SPINE WITH AND W/O CONTRAST,26116,CDM,352,RC,72130,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
CT scan of abdomen and pelvis with contrast,26153,CDM,352,RC,74177,HCPCS,Outpatient,,,1900.25,1140.15,,1615.21,85,,1292.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1520.77,80.03,,1216.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1710.23,90,,1368.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,610.93,32.15,,488.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1672.22,88,,1337.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,629.17,33.11,,503.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,610.93,1710.23,
NM CARDIAC BLOOD POOL MULTI STUDIES,2378473,CDM,341,RC,78473,HCPCS,Outpatient,,,1911,1146.6,,1624.35,85,,1299.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,614.39,32.15,,491.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1529.37,80.03,,1223.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1719.9,90,,1375.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,614.39,32.15,,491.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,614.39,32.15,,491.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1681.68,88,,1345.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,632.73,33.11,,506.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,614.39,1719.9,
(E) US OB MULT GEST,24097,CDM,402,RC,76810,HCPCS,Outpatient,,,1911,1146.6,,1624.35,85,,1299.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,614.39,32.15,,491.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1529.37,80.03,,1223.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1719.9,90,,1375.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,614.39,32.15,,491.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1911,,,,Other,Not Separately reimbursable,614.39,32.15,,491.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1681.68,88,,1345.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,632.73,33.11,,506.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,614.39,1719.9,
CATHETER DOMESTIC III THERMACHOICE,4999027,CDM,270,RC,,,Outpatient,,,1927,1156.2,,1637.95,85,,1310.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,619.53,32.15,,495.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1542.18,80.03,,1233.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1734.3,90,,1387.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,619.53,32.15,,495.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1927,,,,Other,Not Separately reimbursable,619.53,32.15,,495.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1695.76,88,,1356.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,638.03,33.11,,510.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,619.53,1734.3,
UBE3A GENE ANALYSIS  (MAYO),1884804,CDM,300,RC,81406,HCPCS,Outpatient,,,1927.25,1156.35,,1638.16,85,,1310.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1542.38,80.03,,1233.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,288.53,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,1734.53,90,,1387.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,288.53,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1695.98,88,,1356.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,535.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,520,1734.53,
RABIES (HYPERRAB) IMMUNE GLOBULIN 1ML,293413,CDM,636,RC,90375,HCPCS,Outpatient,,,1930.88,1158.53,,1641.25,85,,1313,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,277.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1545.28,80.03,,1236.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,283.29,102,,,fee schedule,Pays at 102% of CMS APC rate,1737.79,90,,1390.23,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,277.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,283.29,100,,,fee schedule,Pays at 100% of CMS APC rate,277.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1699.17,88,,1359.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,286.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,277.74,1737.79,
APPLICATION SKIN SUB GRAFT/FACE/SCALP,15277,CDM,761,RC,15277,HCPCS,Outpatient,,,1947.75,1168.65,,1655.59,85,,1324.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,626.2,32.15,,500.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1558.78,80.03,,1247.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,1752.98,90,,1402.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,626.2,32.15,,500.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,626.2,32.15,,500.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1714.02,88,,1371.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,644.9,33.11,,515.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,626.2,1752.98,
NM CEREBROSPINAL FLUID FLOW,2378630,CDM,341,RC,78630,HCPCS,Outpatient,,,1960.5,1176.3,,1666.43,85,,1333.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,630.3,32.15,,504.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1568.99,80.03,,1255.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,1764.45,90,,1411.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,630.3,32.15,,504.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,630.3,32.15,,504.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1725.24,88,,1380.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,649.12,33.11,,519.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,630.3,1764.45,
MRA OF CHEST WITH AND WITHOUT,27088,CDM,610,RC,71555,HCPCS,Outpatient,,,1995.75,1197.45,,1696.39,85,,1357.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,641.63,32.15,,513.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1597.2,80.03,,1277.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1796.18,90,,1436.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,641.63,32.15,,513.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,641.63,32.15,,513.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1756.26,88,,1405.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,660.79,33.11,,528.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,641.63,1796.18,
NM PULMONARY QUANTITATIVE DIFF FUNCTION,2378596,CDM,341,RC,78597,HCPCS,Outpatient,,,2020.75,1212.45,,1717.64,85,,1374.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,649.67,32.15,,519.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1617.21,80.03,,1293.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1818.68,90,,1454.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,649.67,32.15,,519.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,649.67,32.15,,519.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1778.26,88,,1422.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,669.07,33.11,,535.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,649.67,1818.68,
(E) NM LIMITED AREA WBC IMAGING,23027,CDM,341,RC,78805,HCPCS,Outpatient,,,2041,1224.6,,1734.85,85,,1387.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,656.18,32.15,,524.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1633.41,80.03,,1306.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1836.9,90,,1469.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,656.18,32.15,,524.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,656.18,32.15,,524.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1796.08,88,,1436.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,675.78,33.11,,540.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,656.18,1836.9,
HEMOPERFUSION DIALYSIS,17002,CDM,801,RC,,,Outpatient,,,2041,1224.6,,1734.85,85,,1387.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,656.18,32.15,,524.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1633.41,80.03,,1306.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1836.9,90,,1469.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,656.18,32.15,,524.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,656.18,32.15,,524.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1796.08,88,,1436.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,675.78,33.11,,540.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,656.18,1836.9,
INTRAVENOUS IMMUNE GLOBULIN 5GM/50ML,299915,CDM,636,RC,J1459,HCPCS,Outpatient,,,2044,1226.4,,1737.4,85,,1389.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1635.81,80.03,,1308.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.54,102,,,fee schedule,Pays at 102% of CMS APC rate,1839.6,90,,1471.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.54,100,,,fee schedule,Pays at 100% of CMS APC rate,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1798.72,88,,1438.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,47.59,1839.6,
ADD ORTHO KNEE/SHOULDER 15 MIN,110011,CDM,360,RC,,,Outpatient,,,2066.56,1239.94,,1756.58,85,,1405.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,664.4,32.15,,531.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1653.87,80.03,,1323.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1859.9,90,,1487.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,664.4,32.15,,531.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,664.4,32.15,,531.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1818.57,88,,1454.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,684.24,33.11,,547.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,664.4,1859.9,
SEALER/DIVIDER IMPAC73T LIGASURE,4980116,CDM,270,RC,A4649,HCPCS,Outpatient,,,2075,1245,,1763.75,85,,1411,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,667.11,32.15,,533.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1660.62,80.03,,1328.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1867.5,90,,1494,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,667.11,32.15,,533.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,667.11,32.15,,533.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1826,88,,1460.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,687.03,33.11,,549.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,667.11,1867.5,
PICC LINE INSERTION PROCEDURE,4022,CDM,761,RC,36569,HCPCS,Outpatient,,,2087.72,1252.63,,1774.56,85,,1419.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,671.2,32.15,,536.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1670.8,80.03,,1336.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,1878.95,90,,1503.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,671.2,32.15,,536.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,671.2,32.15,,536.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1837.19,88,,1469.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,691.24,33.11,,552.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,671.2,1878.95,
MIDLINE INSERTION PROCEDURE,4023,CDM,761,RC,36410,HCPCS,Outpatient,,,2087.72,1252.63,,1774.56,85,,1419.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,671.2,32.15,,536.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1670.8,80.03,,1336.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1878.95,90,,1503.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,671.2,32.15,,536.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,671.2,32.15,,536.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1837.19,88,,1469.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,691.24,33.11,,552.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,671.2,1878.95,
RECLAST (zoledronic acid) 5MG INFUSION,293365,CDM,636,RC,J3489,HCPCS,Outpatient,,,2100,1260,,1785,85,,1428,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1680.63,80.03,,1344.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1890,90,,1512,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,6.93,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1848,88,,1478.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7.14,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.93,1890,
PORT US OB MULT GEST,24101,CDM,402,RC,76810,HCPCS,Outpatient,,,2110,1266,,1793.5,85,,1434.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,678.37,32.15,,542.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1688.63,80.03,,1350.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1899,90,,1519.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,678.37,32.15,,542.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,678.37,32.15,,542.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1856.8,88,,1485.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,698.62,33.11,,558.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,678.37,1899,
MRA HEAD WWO CONTRAST,22320,CDM,320,RC,70546,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI ORBIT WWO CONTRAST,22314,CDM,610,RC,70543,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI of upper extremity without dye,27028,CDM,610,RC,73221,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI THYROID SOFT TISS WWO CONTRAST,27042,CDM,610,RC,70543,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI NECK SOFT TISSUE WWO CONTRAST,27051,CDM,610,RC,70543,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI EXT UP NON-JNT WWO CONTRAST RT,27059,CDM,610,RC,73220,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI EXT UP NON JOINT BILAT WO CONTRAST,27069,CDM,610,RC,73218,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI OF BREAST WITHOUT BILAT,27070,CDM,610,RC,77059,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI OF BREAST WITH  BILAT,27071,CDM,610,RC,77059,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI OF BREAST WITH  AND WITHOUT  UNILAT,27075,CDM,610,RC,77058,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI CHEST WITH AND  WITHOUT  CONTRAST,27084,CDM,610,RC,71552,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI FACE SINUS WITH AND  WO CONTRAST,27086,CDM,610,RC,70543,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI BRACHIAL PLEXUS WWO CONTRAST,27222,CDM,610,RC,70543,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI of lower back with and without dye,27023,CDM,612,RC,72158,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRI of lower extremity joint (knee/ankle) without dye,27031,CDM,614,RC,73721,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
MRA LOWER EXTREMITY W/ORW/O CONTRAST,27076,CDM,616,RC,73725,HCPCS,Outpatient,,,2138,1282.8,,1817.3,85,,1453.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1711.04,80.03,,1368.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1924.2,90,,1539.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,687.37,32.15,,549.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1881.44,88,,1505.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,707.89,33.11,,566.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,687.37,1924.2,
CLSD TX NASAL FX W/O STABILIZATION,1421315,CDM,450,RC,21315,HCPCS,Outpatient,,,2148.75,1289.25,,1826.44,85,,1461.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1719.64,80.03,,1375.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1330.81,102,,,fee schedule,Pays at 102% of CMS APC rate,1933.88,90,,1547.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.81,100,,,fee schedule,Pays at 100% of CMS APC rate,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1890.9,88,,1512.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,711.45,33.11,,569.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,690.82,1933.88,
NASAL HEMOR/ANT/SIMP/UNI,1430801,CDM,450,RC,30801,HCPCS,Outpatient,,,2148.75,1289.25,,1826.44,85,,1461.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1719.64,80.03,,1375.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1330.81,102,,,fee schedule,Pays at 102% of CMS APC rate,1933.88,90,,1547.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.81,100,,,fee schedule,Pays at 100% of CMS APC rate,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1890.9,88,,1512.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,711.45,33.11,,569.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,690.82,1933.88,
NASAL HEMOR/ANT/SIMP/BILAT,1430802,CDM,450,RC,30802,HCPCS,Outpatient,,,2148.75,1289.25,,1826.44,85,,1461.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1719.64,80.03,,1375.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1330.81,102,,,fee schedule,Pays at 102% of CMS APC rate,1933.88,90,,1547.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.81,100,,,fee schedule,Pays at 100% of CMS APC rate,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1890.9,88,,1512.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,711.45,33.11,,569.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,690.82,1933.88,
TRANSTRACH TRACHEOSTOMY,1431603,CDM,450,RC,31603,HCPCS,Outpatient,,,2148.75,1289.25,,1826.44,85,,1461.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1719.64,80.03,,1375.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1330.81,102,,,fee schedule,Pays at 102% of CMS APC rate,1933.88,90,,1547.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.81,100,,,fee schedule,Pays at 100% of CMS APC rate,690.82,32.15,,552.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1890.9,88,,1512.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,711.45,33.11,,569.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,690.82,1933.88,
NM SCAN WBC TAG LEVEL II,23017,CDM,341,RC,78806,HCPCS,Outpatient,,,2177.25,1306.35,,1850.66,85,,1480.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,699.99,32.15,,559.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1742.45,80.03,,1393.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1959.53,90,,1567.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,699.99,32.15,,559.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,699.99,32.15,,559.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1915.98,88,,1532.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,720.89,33.11,,576.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,699.99,1959.53,
LYMPHAZURIN 1% 10MG/ML 5ML VIAL,293439,CDM,636,RC,Q9968,HCPCS,Outpatient,,,2183,1309.8,,1855.55,85,,1484.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,701.83,32.15,,561.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1747.05,80.03,,1397.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7.63,102,,,fee schedule,Pays at 102% of CMS APC rate,1964.7,90,,1571.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,701.83,32.15,,561.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7.63,100,,,fee schedule,Pays at 100% of CMS APC rate,701.83,32.15,,561.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1921.04,88,,1536.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,722.79,33.11,,578.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,701.83,1964.7,
EACH ADD ORTHO HIP 15 MIN,110012,CDM,360,RC,,,Outpatient,,,2189.85,1313.91,,1861.37,85,,1489.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,704.04,32.15,,563.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1752.54,80.03,,1402.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1970.87,90,,1576.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,704.04,32.15,,563.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,704.04,32.15,,563.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1927.07,88,,1541.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,725.06,33.11,,580.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,704.04,1970.87,
MRI EXT LOW W/WO CONTRAST BIL,27039,CDM,616,RC,73720,HCPCS,Outpatient,,,2237.75,1342.65,,1902.09,85,,1521.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,719.44,32.15,,575.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1790.87,80.03,,1432.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,2013.98,90,,1611.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,719.44,32.15,,575.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,719.44,32.15,,575.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1969.22,88,,1575.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,740.92,33.11,,592.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,719.44,2013.98,
(E) NM LUNG SCAN VENT & PERFUSION,23031,CDM,341,RC,78582,HCPCS,Outpatient,,,2290,1374,,1946.5,85,,1557.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,736.24,32.15,,588.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1832.69,80.03,,1466.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,2061,90,,1648.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,736.24,32.15,,588.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,736.24,32.15,,588.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2015.2,88,,1612.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,758.22,33.11,,606.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,736.24,2061,
CARDIOMESSENGER SMART 3G,4999925,CDM,270,RC,,,Outpatient,,,2290.25,1374.15,,1946.71,85,,1557.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,736.32,32.15,,589.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1832.89,80.03,,1466.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2061.23,90,,1648.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,736.32,32.15,,589.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,736.32,32.15,,589.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2015.42,88,,1612.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,758.3,33.11,,606.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,736.32,2061.23,
CYTOGENIC STUDIES: BONE MARROW ASPIRATE,2188264,CDM,310,RC,88264,HCPCS,Outpatient,,,2295,1377,,1950.75,85,,1560.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1836.69,80.03,,1469.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,147.5,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,2065.5,90,,1652.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,147.5,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,156.73,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2019.6,88,,1615.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.43,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,156.73,2065.5,
LUPRON DEPOT (leuprolide) 22.5MG DEPO*NF,293478,CDM,636,RC,J1950,HCPCS,Outpatient,,,2325,1395,,1976.25,85,,1581,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1860.7,80.03,,1488.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1554.82,102,,,fee schedule,Pays at 102% of CMS APC rate,2092.5,90,,1674,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1554.82,100,,,fee schedule,Pays at 100% of CMS APC rate,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2046,88,,1636.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1570.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1524.34,2092.5,
Sleep monitoring of patient (6 years or older) in sleep lab,30104,CDM,920,RC,95810,HCPCS,Outpatient,,,2336,1401.6,,1985.6,85,,1588.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,751.02,32.15,,600.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1869.5,80.03,,1495.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,895.78,102,,,fee schedule,Pays at 102% of CMS APC rate,2102.4,90,,1681.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,751.02,32.15,,600.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,895.78,100,,,fee schedule,Pays at 100% of CMS APC rate,751.02,32.15,,600.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2055.68,88,,1644.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,773.45,33.11,,618.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,751.02,2102.4,
Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,30291,CDM,920,RC,95811,HCPCS,Outpatient,,,2336,1401.6,,1985.6,85,,1588.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,751.02,32.15,,600.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1869.5,80.03,,1495.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,895.78,102,,,fee schedule,Pays at 102% of CMS APC rate,2102.4,90,,1681.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,751.02,32.15,,600.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,895.78,100,,,fee schedule,Pays at 100% of CMS APC rate,751.02,32.15,,600.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2055.68,88,,1644.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,773.45,33.11,,618.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,751.02,2102.4,
"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",26154,CDM,352,RC,74178,HCPCS,Outpatient,,,2354.75,1412.85,,2001.54,85,,1601.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,757.05,32.15,,605.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1884.51,80.03,,1507.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,2119.28,90,,1695.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,757.05,32.15,,605.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,757.05,32.15,,605.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2072.18,88,,1657.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,779.66,33.11,,623.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,757.05,2119.28,
O/T DORSAL BLOCKING SPLINT WITH DYNAMICS,3916,CDM,430,RC,L3901,HCPCS,Outpatient,,,2361,1416.6,,2006.85,85,,1605.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,759.06,32.15,,607.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1889.51,80.03,,1511.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2124.9,90,,1699.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,759.06,32.15,,607.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,759.06,32.15,,607.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2077.68,88,,1662.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,781.73,33.11,,625.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,759.06,2124.9,
STRESS THALLIUM (SPECT),2378465,CDM,482,RC,93017,HCPCS,Outpatient,,,2368.75,1421.25,,2013.44,85,,1610.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,761.55,32.15,,609.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1895.71,80.03,,1516.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.49,102,,,fee schedule,Pays at 102% of CMS APC rate,2131.88,90,,1705.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,761.55,32.15,,609.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.49,100,,,fee schedule,Pays at 100% of CMS APC rate,761.55,32.15,,609.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2084.5,88,,1667.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,784.29,33.11,,627.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,761.55,2131.88,
MESH PELVISOFT 8X12 COLIAGEN,4999028,CDM,278,RC,C1713,HCPCS,Outpatient,,,2385.25,1431.15,,2027.46,85,,1621.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,766.86,32.15,,613.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1908.92,80.03,,1527.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2146.73,90,,1717.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,766.86,32.15,,613.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,766.86,32.15,,613.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2099.02,88,,1679.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,789.76,33.11,,631.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,766.86,2146.73,
MESH PELVICOL TISSUE 8X12,4999026,CDM,278,RC,C1713,HCPCS,Outpatient,,,2385.75,1431.45,,2027.89,85,,1622.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,767.02,32.15,,613.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1909.32,80.03,,1527.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2147.18,90,,1717.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,767.02,32.15,,613.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,767.02,32.15,,613.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2099.46,88,,1679.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,789.92,33.11,,631.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,767.02,2147.18,
(E) NM RENAL W/FLOW,23032,CDM,341,RC,78707,HCPCS,Outpatient,,,2439.75,1463.85,,2073.79,85,,1659.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,784.38,32.15,,627.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1952.53,80.03,,1562.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,2195.78,90,,1756.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,784.38,32.15,,627.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,784.38,32.15,,627.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2146.98,88,,1717.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,807.8,33.11,,646.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,784.38,2195.78,
NM RENAL WITH AND W/O PHARMACOLOGICAL,23041,CDM,341,RC,78709,HCPCS,Outpatient,,,2439.75,1463.85,,2073.79,85,,1659.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,784.38,32.15,,627.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1952.53,80.03,,1562.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,2195.78,90,,1756.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,784.38,32.15,,627.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,784.38,32.15,,627.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2146.98,88,,1717.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,807.8,33.11,,646.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,784.38,2195.78,
PELVILACE,4980080,CDM,278,RC,C1781,HCPCS,Outpatient,,,2451,1470.6,,2083.35,85,,1666.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,788,32.15,,630.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1961.54,80.03,,1569.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2205.9,90,,1764.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,788,32.15,,630.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,788,32.15,,630.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2156.88,88,,1725.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,811.53,33.11,,649.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,788,2205.9,
ORTHO OTHER 1ST 30 MIN,110022,CDM,360,RC,,,Outpatient,,,2500,1500,,2125,85,,1700,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,803.75,32.15,,643,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2000.75,80.03,,1600.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2250,90,,1800,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,803.75,32.15,,643,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,803.75,32.15,,643,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2200,88,,1760,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,827.75,33.11,,662.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,803.75,2250,
CLSD TX CLAVICLE FX W/MANIP,1423505,CDM,450,RC,23505,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX CLAVICLE DISLOC W/O MANIP,1423520,CDM,450,RC,23520,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX PROXIMAL HUMERAL TUBEROSITY FX W,1423625,CDM,450,RC,23625,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
SHOULDER REDUCTION/C ANES,1423655,CDM,450,RC,23655,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
TX SHOULDER DISLOC W/HUMERAL FX W/O MANI,1423665,CDM,450,RC,23665,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX SHOULDER DISLOC W/SURGICAL NECK,1423675,CDM,450,RC,23675,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX SUPRA OR TRANSCONDYLAR HUMERAL F,1424535,CDM,450,RC,24535,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX HUMERAL EPICONDYLAR FX W/MANIP,1424565,CDM,450,RC,24565,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX HUMERAL CONDYLAR FX W/MANIP,1424577,CDM,450,RC,24577,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX MONTEGGIA TYPE ELBOW FX W/MANIP,1424620,CDM,450,RC,24620,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX FX RADIAL HD W/MANIP,1424655,CDM,450,RC,24655,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX ULNA FX PROXIMAL END W/MANIP,1424675,CDM,450,RC,24675,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX RADIAL SHAFT FX W/MANI,1425505,CDM,450,RC,25505,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX RADIAL SHAFT FX W/DISLOC OF RU J,1425520,CDM,450,RC,25520,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX FX RADIUS & ULNA W/MANIP,1425565,CDM,450,RC,25565,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX DISTAL RADIAL FX W/MAN,1425605,CDM,450,RC,25605,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX CARPAL SCAPOID FX W/MANIPEA,1425624,CDM,450,RC,25624,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX CARPAL BONE FX  W/MANIP EA,1425635,CDM,450,RC,25635,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX LUNATE DISLOC W/MANIP,1425690,CDM,450,RC,25690,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
EX TEND REP/SPLINT MALLET FING,1426432,CDM,450,RC,26432,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX CARPO-MC DISLOC (THUMB) W/MANIP,1426645,CDM,450,RC,26645,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
METACARPAL DISLOC CLOSED/C ANE,1426705,CDM,450,RC,26705,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX ARTICULAR FX W/ MAN,1426742,CDM,450,RC,26742,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
"CLSD TX INTRO, PERTRO, OF SUBTROCHANTERI",1427238,CDM,450,RC,27238,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
KNEE DISLOCATION REPAIR,1427552,CDM,450,RC,27552,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX TIBIAL FX W/ MANIP,1427752,CDM,450,RC,27752,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX FX MED. MALLEOLUS W/ MANIP,1427762,CDM,450,RC,27762,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX BIMALLEOLAR ANKLE FX W/ MANIP,1427810,CDM,450,RC,27810,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX TRIMALLEOLAR ANKLE FX W/MANIP,1427818,CDM,450,RC,27818,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
CLSD TX TALUS FX W/ MANIP,1428435,CDM,450,RC,28435,HCPCS,Outpatient,,,2519.25,1511.55,,2141.36,85,,1713.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2016.16,80.03,,1612.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2267.33,90,,1813.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,809.94,32.15,,647.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2216.94,88,,1773.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,834.12,33.11,,667.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,809.94,2267.33,
LUPRON DEPOT (leuprolide) 7.5MG INJ*NF,293476,CDM,636,RC,J1950,HCPCS,Outpatient,,,2530,1518,,2150.5,85,,1720.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2024.76,80.03,,1619.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1554.82,102,,,fee schedule,Pays at 102% of CMS APC rate,2277,90,,1821.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1554.82,100,,,fee schedule,Pays at 100% of CMS APC rate,1524.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2226.4,88,,1781.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1570.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1524.34,2277,
CVC PERCUTANEOUS > 2YO,22301,CDM,360,RC,36569,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
CVC PERCUTANEUOS > 5YO,336556,CDM,360,RC,36556,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
CVC PERCUTANEUOS > 5YO,1036556,CDM,360,RC,36556,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
LEVEL 1 VASCULAR PROCEDURES,1132551,CDM,360,RC,32551,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
CVC PERCUTANEUOS > 5YO,1536556,CDM,360,RC,36556,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
CVC PERCUTANEUOS > 2YO,3006,CDM,450,RC,36555,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
CHEST TUBE,1432020,CDM,450,RC,32551,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
CVC PERCUTANEUOS > 5YO,1436489,CDM,450,RC,36556,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
PICC CATH EXCHANGE,4025,CDM,761,RC,36584,HCPCS,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
LEVEL 2 VASCULAR PROCEDURES,9240,CDM,790,RC,,,Outpatient,,,2543,1525.8,,2161.55,85,,1729.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2035.16,80.03,,1628.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2288.7,90,,1830.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,817.57,32.15,,654.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2237.84,88,,1790.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,841.99,33.11,,673.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,817.57,2288.7,
I & REM F.B. COMPLICATED,1410121,CDM,450,RC,10121,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
"Incision and drainage of hematoma, seroma or fluid collection",1410140,CDM,450,RC,10140,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
"INCISION OF SOFT TISSUE ABSCESS, SUPERFI",1420000,CDM,450,RC,20005,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
"INCISION OF SOFT TISSUE ABSCESS, DEEP/CO",1420005,CDM,450,RC,20005,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
FB REM MUSCLE SIMPLE,1420520,CDM,450,RC,20520,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
I & D UPPER ARM OR ELBOW AREA DEEP ABSCE,1423930,CDM,450,RC,23930,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2476.56,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2476.56,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
I & D FINGER ABSCESS COMPLETE,1426011,CDM,450,RC,26011,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
"REMOVAL OF F.B. FOOT, DEEP",1428192,CDM,450,RC,28192,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
"REMOVAL OF F.B. FOOT, COMP",1428193,CDM,450,RC,28193,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
DRAIN EXTERNAL ABSCESS/HEMATOMA-COMPLICA,1469005,CDM,450,RC,69005,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
"Incision and drainage of hematoma, seroma or fluid collection",8410140,CDM,761,RC,10140,HCPCS,Outpatient,,,2558.5,1535.1,,2174.73,85,,1739.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2047.57,80.03,,1638.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2302.65,90,,1842.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,822.56,32.15,,658.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2251.48,88,,1801.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,847.12,33.11,,677.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,822.56,2302.65,
"LARYNGOSCOPY, FLEX FIBEROPTIC W/BIOPSY",1431576,CDM,450,RC,31576,HCPCS,Outpatient,,,2627.75,1576.65,,2233.59,85,,1786.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,844.82,32.15,,675.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2102.99,80.03,,1682.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1532.54,102,,,fee schedule,Pays at 102% of CMS APC rate,2364.98,90,,1891.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,844.82,32.15,,675.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1532.54,100,,,fee schedule,Pays at 100% of CMS APC rate,844.82,32.15,,675.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2312.42,88,,1849.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,870.05,33.11,,696.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,844.82,2364.98,
MRI AUTOMATED VACUUM ASSISTED BIOPSY,27096,CDM,320,RC,19085,HCPCS,Outpatient,,,2633.5,1580.1,,2238.48,85,,1790.78,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,846.67,32.15,,677.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2107.59,80.03,,1686.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2370.15,90,,1896.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,846.67,32.15,,677.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,846.67,32.15,,677.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2317.48,88,,1853.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,871.95,33.11,,697.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,846.67,2370.15,
SYNAGIS  (palivizumab) 100MG VIAL,293516,CDM,636,RC,C9113,HCPCS,Outpatient,,,2635.95,1581.57,,2240.56,85,,1792.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,847.46,32.15,,677.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2109.55,80.03,,1687.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2372.36,90,,1897.89,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,847.46,32.15,,677.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,847.46,32.15,,677.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2319.64,88,,1855.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,872.76,33.11,,698.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,847.46,2372.36,
TISSUE 2 X 24 SUSPEND FACIA LATA,4980096,CDM,278,RC,C1713,HCPCS,Outpatient,,,2648.5,1589.1,,2251.23,85,,1800.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,851.49,32.15,,681.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2119.59,80.03,,1695.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2383.65,90,,1906.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,851.49,32.15,,681.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,851.49,32.15,,681.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2330.68,88,,1864.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,876.92,33.11,,701.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,851.49,2383.65,
Image of the heart to assess perfusion,23020,CDM,341,RC,78452,HCPCS,Outpatient,,,2698,1618.8,,2293.3,85,,1834.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,867.41,32.15,,693.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2159.21,80.03,,1727.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,2428.2,90,,1942.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,867.41,32.15,,693.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,867.41,32.15,,693.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2374.24,88,,1899.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,893.31,33.11,,714.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,867.41,2428.2,
(E) NM GI BLEED,23057,CDM,341,RC,78278,HCPCS,Outpatient,,,2700.75,1620.45,,2295.64,85,,1836.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,868.29,32.15,,694.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2161.41,80.03,,1729.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2430.68,90,,1944.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,868.29,32.15,,694.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,868.29,32.15,,694.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2376.66,88,,1901.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,894.22,33.11,,715.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,868.29,2430.68,
(E) PULMONARY QUANTITATIVE DIFF FUNCTION,2370001,CDM,341,RC,78597,HCPCS,Outpatient,,,2707.75,1624.65,,2301.59,85,,1841.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,870.54,32.15,,696.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2167.01,80.03,,1733.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2436.98,90,,1949.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,870.54,32.15,,696.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,870.54,32.15,,696.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2382.82,88,,1906.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,896.54,33.11,,717.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,870.54,2436.98,
NM TC99M EXAMETAZIME OR CERETEC,291096,CDM,636,RC,A9521,HCPCS,Outpatient,,,2725.45,1635.27,,2316.63,85,,1853.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,876.23,32.15,,700.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2181.18,80.03,,1744.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2452.91,90,,1962.33,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,876.23,32.15,,700.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,876.23,32.15,,700.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2398.4,88,,1918.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,902.4,33.11,,721.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,876.23,2452.91,
Sleep monitoring of patient (6 years or older) in sleep lab,30105,CDM,920,RC,95810,HCPCS,Outpatient,,,2727.75,1636.65,,2318.59,85,,1854.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,876.97,32.15,,701.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2183.02,80.03,,1746.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,895.78,102,,,fee schedule,Pays at 102% of CMS APC rate,2454.98,90,,1963.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,876.97,32.15,,701.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,895.78,100,,,fee schedule,Pays at 100% of CMS APC rate,876.97,32.15,,701.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2400.42,88,,1920.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,903.16,33.11,,722.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,876.97,2454.98,
CT EXTREM UP W/O CONTRAST BIL,26121,CDM,352,RC,73200,HCPCS,Outpatient,,,2787.25,1672.35,,2369.16,85,,1895.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,896.1,32.15,,716.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2230.64,80.03,,1784.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,2508.53,90,,2006.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,896.1,32.15,,716.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,896.1,32.15,,716.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2452.78,88,,1962.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,922.86,33.11,,738.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,896.1,2508.53,
CT BILATERAL  EXTREM UP W/O CONTRAST,26156,CDM,352,RC,73200,HCPCS,Outpatient,,,2787.25,1672.35,,2369.16,85,,1895.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,896.1,32.15,,716.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2230.64,80.03,,1784.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,2508.53,90,,2006.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,896.1,32.15,,716.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,896.1,32.15,,716.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2452.78,88,,1962.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,922.86,33.11,,738.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,896.1,2508.53,
THORACENTESIS,9046,CDM,360,RC,,,Outpatient,,,2882.75,1729.65,,2450.34,85,,1960.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,926.8,32.15,,741.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2307.06,80.03,,1845.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2594.48,90,,2075.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,926.8,32.15,,741.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,926.8,32.15,,741.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2536.82,88,,2029.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,954.48,33.11,,763.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,926.8,2594.48,
APP LOW COST SKIN SUB GRAFT ADD 100CM,8415274,CDM,761,RC,15274,HCPCS,Outpatient,,,2901.5,1740.9,,2466.28,85,,1973.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,932.83,32.15,,746.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2322.07,80.03,,1857.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.35,90,,2089.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,932.83,32.15,,746.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,932.83,32.15,,746.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2553.32,88,,2042.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,960.69,33.11,,768.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,932.83,2611.35,
INT LAC >30.0 CM NHF,1412047,CDM,450,RC,12047,HCPCS,Outpatient,,,2954,1772.4,,2510.9,85,,2008.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2364.09,80.03,,1891.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,2658.6,90,,2126.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2599.52,88,,2079.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,978.07,33.11,,782.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,949.71,2658.6,
EXPLORATION OF PENETRATING WOUND CHEST,1420101,CDM,450,RC,20101,HCPCS,Outpatient,,,2954,1772.4,,2510.9,85,,2008.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2364.09,80.03,,1891.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,2658.6,90,,2126.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2599.52,88,,2079.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,978.07,33.11,,782.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,949.71,2658.6,
EXPLORATION PENETRATING WOUND ABD/FLANK/,1420102,CDM,450,RC,20102,HCPCS,Outpatient,,,2954,1772.4,,2510.9,85,,2008.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2364.09,80.03,,1891.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,2658.6,90,,2126.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,949.71,32.15,,759.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2599.52,88,,2079.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,978.07,33.11,,782.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,949.71,2658.6,
"ATP7B, ATPASE  (MAYO)",1883910,CDM,300,RC,81406,HCPCS,Outpatient,,,2995.75,1797.45,,2546.39,85,,2037.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2397.5,80.03,,1918,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,288.53,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,2696.18,90,,2156.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,288.53,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2636.26,88,,2109.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,535.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,520,2696.18,
LUPRON DEPOT (PED)(LEUPROLIDE) 11.25MG,293411,CDM,636,RC,J9217,HCPCS,Outpatient,,,3000,1800,,2550,85,,2040,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,166.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2400.9,80.03,,1920.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,170.02,102,,,fee schedule,Pays at 102% of CMS APC rate,2700,90,,2160,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,166.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,170.02,100,,,fee schedule,Pays at 100% of CMS APC rate,166.69,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2640,88,,2112,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,171.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,166.69,2700,
CHROMOSOMAL MICROARRAY   (MAYO),1881229,CDM,300,RC,81229,HCPCS,Outpatient,,,3000.25,1800.15,,2550.21,85,,2040.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2320,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2401.1,80.03,,1920.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1183.2,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,2700.23,90,,2160.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2320,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1183.2,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,2320,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2640.22,88,,2112.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2389.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,2320,2700.23,
LEVEL 2 LOWER GI PROCEDURES,9230,CDM,750,RC,,,Outpatient,,,3028.75,1817.25,,2574.44,85,,2059.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,973.74,32.15,,778.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2423.91,80.03,,1939.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2725.88,90,,2180.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,973.74,32.15,,778.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,973.74,32.15,,778.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2665.3,88,,2132.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1002.82,33.11,,802.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,973.74,2725.88,
KIT POSTERIOR AVAULTA PLUS,4999010,CDM,278,RC,C1771,HCPCS,Outpatient,,,3029.25,1817.55,,2574.86,85,,2059.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,973.9,32.15,,779.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2424.31,80.03,,1939.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2726.33,90,,2181.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,973.9,32.15,,779.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,973.9,32.15,,779.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2665.74,88,,2132.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1002.98,33.11,,802.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,973.9,2726.33,
KIT ANTERIOR AVAULTA PLUS,4999009,CDM,278,RC,C1771,HCPCS,Outpatient,,,3029.5,1817.7,,2575.08,85,,2060.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,973.98,32.15,,779.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2424.51,80.03,,1939.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2726.55,90,,2181.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,973.98,32.15,,779.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,973.98,32.15,,779.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2665.96,88,,2132.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1003.07,33.11,,802.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,973.98,2726.55,
** DO NOT USE* VESPRIN 20MG*,293204,CDM,250,RC,,,Outpatient,,,3039,1823.4,,2583.15,85,,2066.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,977.04,32.15,,781.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2432.11,80.03,,1945.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2735.1,90,,2188.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,977.04,32.15,,781.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,977.04,32.15,,781.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2674.32,88,,2139.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1006.21,33.11,,804.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,977.04,2735.1,
(E) GASTROINTESTINAL BLOOD LOSS STUDY,2370000,CDM,341,RC,78278,HCPCS,Outpatient,,,3066.25,1839.75,,2606.31,85,,2085.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,985.8,32.15,,788.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2453.92,80.03,,1963.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,2759.63,90,,2207.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,985.8,32.15,,788.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,985.8,32.15,,788.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2698.3,88,,2158.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1015.24,33.11,,812.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,985.8,2759.63,
BRCANEXT-EXPANDED (MAYO),1881432,CDM,300,RC,81432,HCPCS,Outpatient,,,3087.5,1852.5,,2624.38,85,,2099.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,992.63,32.15,,794.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2470.93,80.03,,1976.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,692.63,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,2778.75,90,,2223,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,992.63,32.15,,794.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,692.63,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,992.63,32.15,,794.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2717,88,,2173.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1022.27,33.11,,817.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,992.63,2778.75,
MRI OF BREAST WITH AND WITHOUT BILAT,27072,CDM,610,RC,77059,HCPCS,Outpatient,,,3088,1852.8,,2624.8,85,,2099.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,992.79,32.15,,794.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2471.33,80.03,,1977.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2779.2,90,,2223.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,992.79,32.15,,794.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,992.79,32.15,,794.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2717.44,88,,2173.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1022.44,33.11,,817.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,992.79,2779.2,
MRI EXT UP JOINT BILAT WWO CONTRAST,27225,CDM,610,RC,73223,HCPCS,Outpatient,,,3088,1852.8,,2624.8,85,,2099.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,992.79,32.15,,794.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2471.33,80.03,,1977.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,2779.2,90,,2223.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,992.79,32.15,,794.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,992.79,32.15,,794.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2717.44,88,,2173.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1022.44,33.11,,817.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,992.79,2779.2,
XOLAIR ( omalizumab) 202.5 MG INJ,293586,CDM,636,RC,J2357,HCPCS,Outpatient,,,3184,1910.4,,2706.4,85,,2165.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2548.16,80.03,,2038.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,39.86,102,,,fee schedule,Pays at 102% of CMS APC rate,2865.6,90,,2292.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,39.86,100,,,fee schedule,Pays at 100% of CMS APC rate,39.09,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2801.92,88,,2241.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,39.09,2865.6,
Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,30106,CDM,920,RC,95811,HCPCS,Outpatient,,,3270.5,1962.3,,2779.93,85,,2223.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1051.47,32.15,,841.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2617.38,80.03,,2093.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,895.78,102,,,fee schedule,Pays at 102% of CMS APC rate,2943.45,90,,2354.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1051.47,32.15,,841.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,895.78,100,,,fee schedule,Pays at 100% of CMS APC rate,1051.47,32.15,,841.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2878.04,88,,2302.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1082.86,33.11,,866.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1051.47,2943.45,
CALCIMAR: 200UNIT/ML VIAL 2ML,293032,CDM,636,RC,J0630,HCPCS,Outpatient,,,3320,1992,,2822,85,,2257.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1296.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2657,80.03,,2125.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1322.28,102,,,fee schedule,Pays at 102% of CMS APC rate,2988,90,,2390.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1296.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1322.28,100,,,fee schedule,Pays at 100% of CMS APC rate,1296.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2921.6,88,,2337.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1335.25,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1296.36,2988,
ACTEMRA (tocilizumab) 200mg/10mL INJ,304162,CDM,250,RC,J3262,HCPCS,Outpatient,,,3320.35,1992.21,,2822.3,85,,2257.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2657.28,80.03,,2125.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6.31,102,,,fee schedule,Pays at 102% of CMS APC rate,2988.32,90,,2390.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6.31,100,,,fee schedule,Pays at 100% of CMS APC rate,6.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2921.91,88,,2337.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,6.19,2988.32,
"NUSHIELD, PER 1 SQUARE CENTIMETER",844160,CDM,278,RC,Q4160,HCPCS,Outpatient,,,3325,1995,,2826.25,85,,2261,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1068.99,32.15,,855.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2661,80.03,,2128.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2992.5,90,,2394,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1068.99,32.15,,855.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1068.99,32.15,,855.19,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2926,88,,2340.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1100.91,33.11,,880.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1068.99,2992.5,
SYSTEM BIRTH CONTROL PERMAMENT ESSURE,4999025,CDM,278,RC,A4264,HCPCS,Outpatient,,,3351.75,2011.05,,2848.99,85,,2279.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1077.59,32.15,,862.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2682.41,80.03,,2145.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3016.58,90,,2413.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1077.59,32.15,,862.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1077.59,32.15,,862.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2949.54,88,,2359.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1109.76,33.11,,887.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1077.59,3016.58,
LONG QT SYN MULT-GENE PANEL  (MAYO),1882698,CDM,300,RC,81280,HCPCS,Outpatient,,,3352.25,2011.35,,2849.41,85,,2279.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1077.75,32.15,,862.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2682.81,80.03,,2146.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3017.03,90,,2413.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1077.75,32.15,,862.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1077.75,32.15,,862.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2949.98,88,,2359.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1109.93,33.11,,887.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1077.75,3017.03,
APPLICATION SKIN SUB GRAFT/ARM/LEG 25SQ,15273,CDM,761,RC,15273,HCPCS,Outpatient,,,3366.75,2020.05,,2861.74,85,,2289.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1082.41,32.15,,865.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2694.41,80.03,,2155.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3118.7,102,,,fee schedule,Pays at 102% of CMS APC rate,3030.08,90,,2424.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1082.41,32.15,,865.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3118.7,100,,,fee schedule,Pays at 100% of CMS APC rate,1082.41,32.15,,865.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2962.74,88,,2370.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1114.73,33.11,,891.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1082.41,3030.08,
UROLOGY 1ST 30 MIN,110009,CDM,360,RC,,,Outpatient,,,3371,2022.6,,2865.35,85,,2292.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1083.78,32.15,,867.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2697.81,80.03,,2158.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3033.9,90,,2427.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1083.78,32.15,,867.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1083.78,32.15,,867.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2966.48,88,,2373.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1116.14,33.11,,892.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1083.78,3033.9,
CYSTOSCOPY WITH DIALATION,1452281,CDM,450,RC,52281,HCPCS,Outpatient,,,3403,2041.8,,2892.55,85,,2314.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1094.06,32.15,,875.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2723.42,80.03,,2178.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1778.27,102,,,fee schedule,Pays at 102% of CMS APC rate,3062.7,90,,2450.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1094.06,32.15,,875.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1778.27,100,,,fee schedule,Pays at 100% of CMS APC rate,1094.06,32.15,,875.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2994.64,88,,2395.71,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1126.73,33.11,,901.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1094.06,3062.7,
HISTOCHEM MUSCEL PANEL  (MAYO),2188314,CDM,310,RC,88314,HCPCS,Outpatient,,,3403.75,2042.25,,2893.19,85,,2314.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2724.02,80.03,,2179.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3063.38,90,,2450.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,,,,,Other,Not Separately reimbursable,88.62,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,2995.3,88,,2396.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,91.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,88.62,3063.38,
LEVEL 3 AIRWAY ENDOSCOPY,9310,CDM,790,RC,,,Outpatient,,,3424.75,2054.85,,2911.04,85,,2328.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1101.06,32.15,,880.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2740.83,80.03,,2192.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3082.28,90,,2465.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1101.06,32.15,,880.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1101.06,32.15,,880.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3013.78,88,,2411.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1133.93,33.11,,907.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1101.06,3082.28,
LEVEL 2 EXCISION/BIOPSY/INCIS & DRAINAGE,9250,CDM,360,RC,,,Outpatient,,,3488,2092.8,,2964.8,85,,2371.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1121.39,32.15,,897.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2791.45,80.03,,2233.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3139.2,90,,2511.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1121.39,32.15,,897.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1121.39,32.15,,897.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3069.44,88,,2455.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1154.88,33.11,,923.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1121.39,3139.2,
US RENAL BX,24140,CDM,402,RC,50200,HCPCS,Outpatient,,,3488,2092.8,,2964.8,85,,2371.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1121.39,32.15,,897.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2791.45,80.03,,2233.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,3139.2,90,,2511.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1121.39,32.15,,897.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,1121.39,32.15,,897.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3069.44,88,,2455.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1154.88,33.11,,923.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1121.39,3139.2,
LEVEL 2 MUSCULOSKELATAL PROCEDURES,9255,CDM,790,RC,,,Outpatient,,,3493.25,2095.95,,2969.26,85,,2375.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1123.08,32.15,,898.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2795.65,80.03,,2236.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3143.93,90,,2515.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1123.08,32.15,,898.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1123.08,32.15,,898.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3074.06,88,,2459.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1156.62,33.11,,925.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1123.08,3143.93,
ORTHO HIP 1ST 30 MIN,110007,CDM,360,RC,,,Outpatient,,,3503.76,2102.26,,2978.2,85,,2382.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1126.46,32.15,,901.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2804.06,80.03,,2243.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3153.38,90,,2522.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1126.46,32.15,,901.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1126.46,32.15,,901.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3083.31,88,,2466.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1160.09,33.11,,928.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1126.46,3153.38,
REPAIR CONJUNCT LAC,1465270,CDM,450,RC,65270,HCPCS,Outpatient,,,3521,2112.6,,2992.85,85,,2394.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1132,32.15,,905.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2817.86,80.03,,2254.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2026.91,102,,,fee schedule,Pays at 102% of CMS APC rate,3168.9,90,,2535.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1132,32.15,,905.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2026.91,100,,,fee schedule,Pays at 100% of CMS APC rate,1132,32.15,,905.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3098.48,88,,2478.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1165.8,33.11,,932.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1132,3168.9,
KIT REPAIR TOTAL PELVIC PROLIFT,4999021,CDM,270,RC,,,Outpatient,,,3612,2167.2,,3070.2,85,,2456.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1161.26,32.15,,929.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2890.68,80.03,,2312.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3250.8,90,,2600.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1161.26,32.15,,929.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1161.26,32.15,,929.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3178.56,88,,2542.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1195.93,33.11,,956.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1161.26,3250.8,
LEVEL 2 UPPER GI PROCEDURES,9260,CDM,750,RC,,,Outpatient,,,3693,2215.8,,3139.05,85,,2511.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1187.3,32.15,,949.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2955.51,80.03,,2364.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3323.7,90,,2658.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1187.3,32.15,,949.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1187.3,32.15,,949.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3249.84,88,,2599.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1222.75,33.11,,978.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1187.3,3323.7,
ANTIVENIN-SNAKE 1 VIAL,296004,CDM,636,RC,J0840,HCPCS,Outpatient,,,3739,2243.4,,3178.15,85,,2542.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1202.09,32.15,,961.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2992.32,80.03,,2393.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2117.98,102,,,fee schedule,Pays at 102% of CMS APC rate,3365.1,90,,2692.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1202.09,32.15,,961.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2117.98,100,,,fee schedule,Pays at 100% of CMS APC rate,1202.09,32.15,,961.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3290.32,88,,2632.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1237.98,33.11,,990.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1202.09,3365.1,
EMINASE : 30U VIAL,293085,CDM,636,RC,J0350,HCPCS,Outpatient,,,3751.26,2250.76,,3188.57,85,,2550.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1206.03,32.15,,964.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3002.13,80.03,,2401.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3376.13,90,,2700.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1206.03,32.15,,964.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1206.03,32.15,,964.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3301.11,88,,2640.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1242.04,33.11,,993.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1206.03,3376.13,
DEBRIDEMENT BONE FIRST 20SQ CM OR LESS,11044,CDM,761,RC,11044,HCPCS,Outpatient,,,3755.2,2253.12,,3191.92,85,,2553.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1207.3,32.15,,965.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3005.29,80.03,,2404.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,3379.68,90,,2703.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1207.3,32.15,,965.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,1207.3,32.15,,965.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3304.58,88,,2643.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1243.35,33.11,,994.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1207.3,3379.68,
IMPLANT FM COLLAMEND 4 X 6,4999029,CDM,278,RC,C1713,HCPCS,Outpatient,,,3766,2259.6,,3201.1,85,,2560.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1210.77,32.15,,968.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3013.93,80.03,,2411.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3389.4,90,,2711.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1210.77,32.15,,968.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1210.77,32.15,,968.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3314.08,88,,2651.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1246.92,33.11,,997.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1210.77,3389.4,
POLYCSYTIC KIDNEY DISEASE2  (MAYO),1882048,CDM,300,RC,81406,HCPCS,Outpatient,,,3823,2293.8,,3249.55,85,,2599.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3059.55,80.03,,2447.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,288.53,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,3440.7,90,,2752.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,288.53,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,520,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3364.24,88,,2691.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,535.6,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,520,3440.7,
POLYCSYTIC KIDNEY DISEASE1  (MAYO),1882049,CDM,300,RC,81407,HCPCS,Outpatient,,,3823,2293.8,,3249.55,85,,2599.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,960,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3059.55,80.03,,2447.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,863.19,102,,,fee schedule,Pays at 102% of CMS Custom Fee Schedule for Outpatient Setting,3440.7,90,,2752.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,960,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,863.19,100,,,fee schedule,Pays at 100% of CMS Custom Fee Schedule for Outpatient Setting,960,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3364.24,88,,2691.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,988.8,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,960,3440.7,
CT BIOPSY OF LIVER (CT GUIDED),47000,CDM,320,RC,47000,HCPCS,Outpatient,,,3838,2302.8,,3262.3,85,,2609.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1233.92,32.15,,987.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3071.55,80.03,,2457.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,3454.2,90,,2763.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1233.92,32.15,,987.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,1233.92,32.15,,987.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3377.44,88,,2701.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1270.76,33.11,,1016.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1233.92,3454.2,
CT LUNG BIOPSY,26110,CDM,352,RC,32405,HCPCS,Outpatient,,,3838,2302.8,,3262.3,85,,2609.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1233.92,32.15,,987.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3071.55,80.03,,2457.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3454.2,90,,2763.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1233.92,32.15,,987.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1233.92,32.15,,987.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3377.44,88,,2701.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1270.76,33.11,,1016.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1233.92,3454.2,
LEVEL 2 UPPER GI : CHEST TUBE INSERTION,159260,CDM,360,RC,32556,HCPCS,Outpatient,,,3838.25,2302.95,,3262.51,85,,2610.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1234,32.15,,987.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3071.75,80.03,,2457.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1669.66,102,,,fee schedule,Pays at 102% of CMS APC rate,3454.43,90,,2763.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1234,32.15,,987.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1669.66,100,,,fee schedule,Pays at 100% of CMS APC rate,1234,32.15,,987.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3377.66,88,,2702.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1270.84,33.11,,1016.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1234,3454.43,
NEULASTA (PEGFILGRASTIM) 6MG INJ,293285,CDM,636,RC,J2505,HCPCS,Outpatient,,,3900,2340,,3315,85,,2652,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1253.85,32.15,,1003.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3121.17,80.03,,2496.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3510,90,,2808,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1253.85,32.15,,1003.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,1253.85,32.15,,1003.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3432,88,,2745.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1291.29,33.11,,1033.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1253.85,3510,
CATARACT COMPLEX,110025,CDM,361,RC,66982,HCPCS,Outpatient,,,4043.7,2426.22,,3437.15,85,,2749.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1300.05,32.15,,1040.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3236.17,80.03,,2588.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2070.25,102,,,fee schedule,Pays at 102% of CMS APC rate,3639.33,90,,2911.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1300.05,32.15,,1040.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2070.25,100,,,fee schedule,Pays at 100% of CMS APC rate,1300.05,32.15,,1040.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3558.46,88,,2846.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1338.87,33.11,,1071.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1300.05,3639.33,
KIT LEAD QUADRIPOLAR INTERSTIM 33CM,4999937,CDM,278,RC,,,Outpatient,,,4056.5,2433.9,,3448.03,85,,2758.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1304.16,32.15,,1043.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3246.42,80.03,,2597.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3650.85,90,,2920.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1304.16,32.15,,1043.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4056.5,,,,Other,Not Separately reimbursable,1304.16,32.15,,1043.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3569.72,88,,2855.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1343.11,33.11,,1074.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1304.16,3650.85,
APPLICATION SKIN SUB GRAFT/ARM/LEG,15271,CDM,761,RC,15271,HCPCS,Outpatient,,,4058.25,2434.95,,3449.51,85,,2759.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3247.82,80.03,,2598.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,3652.43,90,,2921.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3571.26,88,,2857.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1343.69,33.11,,1074.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1304.73,3652.43,
APPLICATION SKIN SUB GRAFT/FACE/SCALP,15275,CDM,761,RC,15275,HCPCS,Outpatient,,,4058.25,2434.95,,3449.51,85,,2759.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3247.82,80.03,,2598.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,3652.43,90,,2921.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3571.26,88,,2857.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1343.69,33.11,,1074.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1304.73,3652.43,
LEVEL 4 SKIN PROCEDURES,9440,CDM,790,RC,,,Outpatient,,,4058.25,2434.95,,3449.51,85,,2759.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3247.82,80.03,,2598.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3652.43,90,,2921.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4058.25,,,,Other,Not Separately reimbursable,1304.73,32.15,,1043.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3571.26,88,,2857.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1343.69,33.11,,1074.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1304.73,3652.43,
INTRAVENOUS IMMUNE GLOBULIN 10GM/100ML,299976,CDM,636,RC,J1459,HCPCS,Outpatient,,,4089,2453.4,,3475.65,85,,2780.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3272.43,80.03,,2617.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.54,102,,,fee schedule,Pays at 102% of CMS APC rate,3680.1,90,,2944.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.54,100,,,fee schedule,Pays at 100% of CMS APC rate,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3598.32,88,,2878.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,47.59,3680.1,
KIT METADIAPHEPEAL,4999015,CDM,270,RC,,,Outpatient,,,4108,2464.8,,3491.8,85,,2793.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1320.72,32.15,,1056.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3287.63,80.03,,2630.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3697.2,90,,2957.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1320.72,32.15,,1056.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4108,,,,Other,Not Separately reimbursable,1320.72,32.15,,1056.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3615.04,88,,2892.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1360.16,33.11,,1088.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1320.72,3697.2,
ORTHO KNEE/SHOULDER 1ST 30 MIN,110006,CDM,360,RC,,,Outpatient,,,4133.13,2479.88,,3513.16,85,,2810.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1328.8,32.15,,1063.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3307.74,80.03,,2646.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3719.82,90,,2975.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1328.8,32.15,,1063.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4133.13,,,,Other,Not Separately reimbursable,1328.8,32.15,,1063.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3637.15,88,,2909.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1368.48,33.11,,1094.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1328.8,3719.82,
Image of the heart to assess perfusion,23048,CDM,341,RC,78452,HCPCS,Outpatient,,,4133.75,2480.25,,3513.69,85,,2810.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1329,32.15,,1063.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3308.24,80.03,,2646.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,3720.38,90,,2976.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1329,32.15,,1063.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,1329,32.15,,1063.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3637.7,88,,2910.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1368.68,33.11,,1094.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1329,3720.38,
LEVEL 1 NERVE PROCEDURE (CARPAL TUNNEL),9160,CDM,790,RC,,,Outpatient,,,4167,2500.2,,3541.95,85,,2833.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1339.69,32.15,,1071.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3334.85,80.03,,2667.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3750.3,90,,3000.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1339.69,32.15,,1071.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4167,,,,Other,Not Separately reimbursable,1339.69,32.15,,1071.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3666.96,88,,2933.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1379.69,33.11,,1103.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1339.69,3750.3,
KIT LEAD QUADRIPOLAR INTERSTIM 28CM,4999938,CDM,278,RC,,,Outpatient,,,4205.75,2523.45,,3574.89,85,,2859.91,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1352.15,32.15,,1081.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3365.86,80.03,,2692.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3785.18,90,,3028.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1352.15,32.15,,1081.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4205.75,,,,Other,Not Separately reimbursable,1352.15,32.15,,1081.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3701.06,88,,2960.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1392.52,33.11,,1114.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1352.15,3785.18,
INVEGA SUSTENNA 117MG/ 0.75ML IM INJ,304898,CDM,636,RC,J2426,HCPCS,Outpatient,,,4233.55,2540.13,,3598.52,85,,2878.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3388.11,80.03,,2710.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.62,102,,,fee schedule,Pays at 102% of CMS APC rate,3810.2,90,,3048.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.62,100,,,fee schedule,Pays at 100% of CMS APC rate,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3725.52,88,,2980.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.34,3810.2,
REMOVE TUNNELED CV CATH W/O SUBQ PORT,36589,CDM,360,RC,36589,HCPCS,Outpatient,,,4235.25,2541.15,,3599.96,85,,2879.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1361.63,32.15,,1089.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3389.47,80.03,,2711.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.61,102,,,fee schedule,Pays at 102% of CMS APC rate,3811.73,90,,3049.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1361.63,32.15,,1089.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.61,100,,,fee schedule,Pays at 100% of CMS APC rate,1361.63,32.15,,1089.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3727.02,88,,2981.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1402.29,33.11,,1121.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1361.63,3811.73,
MIACALCIN (calcitonin) 200 IU /ml *2ML,293817,CDM,636,RC,J0630,HCPCS,Outpatient,,,4250,2550,,3612.5,85,,2890,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1296.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3401.28,80.03,,2721.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1322.28,102,,,fee schedule,Pays at 102% of CMS APC rate,3825,90,,3060,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1296.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,1322.28,100,,,fee schedule,Pays at 100% of CMS APC rate,1296.36,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3740,88,,2992,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1335.25,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,1296.36,3825,
DIGIBIND INJ (digoxin immune fab):40MG,296081,CDM,636,RC,J1162,HCPCS,Outpatient,,,4257,2554.2,,3618.45,85,,2894.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1368.63,32.15,,1094.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3406.88,80.03,,2725.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4685.43,102,,,fee schedule,Pays at 102% of CMS APC rate,3831.3,90,,3065.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1368.63,32.15,,1094.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4685.43,100,,,fee schedule,Pays at 100% of CMS APC rate,1368.63,32.15,,1094.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3746.16,88,,2996.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1409.49,33.11,,1127.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1368.63,3831.3,
MARSUPIALIZATION OF BARTHOLIN'S GLAND CY,1456440,CDM,450,RC,56440,HCPCS,Outpatient,,,4315,2589,,3667.75,85,,2934.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3453.29,80.03,,2762.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2710.67,102,,,fee schedule,Pays at 102% of CMS APC rate,3883.5,90,,3106.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2710.67,100,,,fee schedule,Pays at 100% of CMS APC rate,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3797.2,88,,3037.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1428.7,33.11,,1142.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1387.27,3883.5,
COLPOCENTESIS,1457020,CDM,450,RC,57020,HCPCS,Outpatient,,,4315,2589,,3667.75,85,,2934.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3453.29,80.03,,2762.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,4443.7,102,,,fee schedule,Pays at 102% of CMS APC rate,3883.5,90,,3106.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4443.7,100,,,fee schedule,Pays at 100% of CMS APC rate,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3797.2,88,,3037.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1428.7,33.11,,1142.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1387.27,3883.5,
D & C,1458120,CDM,450,RC,59812,HCPCS,Outpatient,,,4315,2589,,3667.75,85,,2934.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3453.29,80.03,,2762.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2710.67,102,,,fee schedule,Pays at 102% of CMS APC rate,3883.5,90,,3106.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2710.67,100,,,fee schedule,Pays at 100% of CMS APC rate,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3797.2,88,,3037.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1428.7,33.11,,1142.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1387.27,3883.5,
Vaginal delivery,1459409,CDM,450,RC,59409,HCPCS,Outpatient,,,4315,2589,,3667.75,85,,2934.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3453.29,80.03,,2762.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2710.67,102,,,fee schedule,Pays at 102% of CMS APC rate,3883.5,90,,3106.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2710.67,100,,,fee schedule,Pays at 100% of CMS APC rate,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3797.2,88,,3037.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1428.7,33.11,,1142.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1387.27,3883.5,
Vaginal delivery of placenta,1459414,CDM,450,RC,59414,HCPCS,Outpatient,,,4315,2589,,3667.75,85,,2934.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3453.29,80.03,,2762.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2710.67,102,,,fee schedule,Pays at 102% of CMS APC rate,3883.5,90,,3106.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2710.67,100,,,fee schedule,Pays at 100% of CMS APC rate,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3797.2,88,,3037.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1428.7,33.11,,1142.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1387.27,3883.5,
"TX OF INCOMPLETE ABORTION, SURGICAL",1459812,CDM,450,RC,59812,HCPCS,Outpatient,,,4315,2589,,3667.75,85,,2934.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3453.29,80.03,,2762.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2710.67,102,,,fee schedule,Pays at 102% of CMS APC rate,3883.5,90,,3106.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2710.67,100,,,fee schedule,Pays at 100% of CMS APC rate,1387.27,32.15,,1109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3797.2,88,,3037.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1428.7,33.11,,1142.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1387.27,3883.5,
Biopsy of prostate gland,24105,CDM,360,RC,55700,HCPCS,Outpatient,,,4387.25,2632.35,,3729.16,85,,2983.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1410.5,32.15,,1128.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3511.12,80.03,,2808.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1778.27,102,,,fee schedule,Pays at 102% of CMS APC rate,3948.53,90,,3158.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1410.5,32.15,,1128.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1778.27,100,,,fee schedule,Pays at 100% of CMS APC rate,1410.5,32.15,,1128.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3860.78,88,,3088.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1452.62,33.11,,1162.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1410.5,3948.53,
LEVEL 3 UROLOGY AND RELATED SERVICES,9320,CDM,790,RC,,,Outpatient,,,4387.25,2632.35,,3729.16,85,,2983.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1410.5,32.15,,1128.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3511.12,80.03,,2808.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3948.53,90,,3158.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1410.5,32.15,,1128.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4387.25,,,,Other,Not Separately reimbursable,1410.5,32.15,,1128.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3860.78,88,,3088.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1452.62,33.11,,1162.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1410.5,3948.53,
DEBRIDE SKIN/BONE AT FRACTURE SITE,1411012,CDM,450,RC,11012,HCPCS,Outpatient,,,4446.25,2667.75,,3779.31,85,,3023.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1429.47,32.15,,1143.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3558.33,80.03,,2846.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2476.56,102,,,fee schedule,Pays at 102% of CMS APC rate,4001.63,90,,3201.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1429.47,32.15,,1143.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2476.56,100,,,fee schedule,Pays at 100% of CMS APC rate,1429.47,32.15,,1143.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3912.7,88,,3130.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1472.15,33.11,,1177.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1429.47,4001.63,
FB REM MUSCLE COMPLEX,1420525,CDM,450,RC,20525,HCPCS,Outpatient,,,4446.25,2667.75,,3779.31,85,,3023.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1429.47,32.15,,1143.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3558.33,80.03,,2846.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2476.56,102,,,fee schedule,Pays at 102% of CMS APC rate,4001.63,90,,3201.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1429.47,32.15,,1143.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2476.56,100,,,fee schedule,Pays at 100% of CMS APC rate,1429.47,32.15,,1143.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3912.7,88,,3130.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1472.15,33.11,,1177.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1429.47,4001.63,
BIOPSY OF RECTUM,1445100,CDM,450,RC,45100,HCPCS,Outpatient,,,4484.75,2690.85,,3812.04,85,,3049.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1441.85,32.15,,1153.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3589.15,80.03,,2871.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2463.35,102,,,fee schedule,Pays at 102% of CMS APC rate,4036.28,90,,3229.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1441.85,32.15,,1153.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2463.35,100,,,fee schedule,Pays at 100% of CMS APC rate,1441.85,32.15,,1153.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3946.58,88,,3157.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1484.9,33.11,,1187.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1441.85,4036.28,
CLSD TX NASAL FX W/STABILIZATION,1421320,CDM,450,RC,21320,HCPCS,Outpatient,,,4498,2698.8,,3823.3,85,,3058.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1446.11,32.15,,1156.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3599.75,80.03,,2879.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2727.54,102,,,fee schedule,Pays at 102% of CMS APC rate,4048.2,90,,3238.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1446.11,32.15,,1156.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2727.54,100,,,fee schedule,Pays at 100% of CMS APC rate,1446.11,32.15,,1156.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3958.24,88,,3166.59,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1489.29,33.11,,1191.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1446.11,4048.2,
MRI of leg without dye,27099,CDM,610,RC,73718,HCPCS,Outpatient,,,4518.75,2711.25,,3840.94,85,,3072.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1452.78,32.15,,1162.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3616.36,80.03,,2893.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,4066.88,90,,3253.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1452.78,32.15,,1162.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,1452.78,32.15,,1162.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3976.5,88,,3181.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1496.16,33.11,,1196.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1452.78,4066.88,
APP LOW COST SKIN SUB GRAFT 1ST 100CM,8415273,CDM,761,RC,15273,HCPCS,Outpatient,,,4539.25,2723.55,,3858.36,85,,3086.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1459.37,32.15,,1167.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3632.76,80.03,,2906.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3118.7,102,,,fee schedule,Pays at 102% of CMS APC rate,4085.33,90,,3268.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1459.37,32.15,,1167.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3118.7,100,,,fee schedule,Pays at 100% of CMS APC rate,1459.37,32.15,,1167.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3994.54,88,,3195.63,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1502.95,33.11,,1202.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1459.37,4085.33,
DALVANCE (dalbavancin) 500MG VIAL,303696,CDM,636,RC,J0875,HCPCS,Outpatient,,,4687.2,2812.32,,3984.12,85,,3187.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,3751.17,80.03,,3000.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,15.51,102,,,fee schedule,Pays at 102% of CMS APC rate,4218.48,90,,3374.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,15.51,100,,,fee schedule,Pays at 100% of CMS APC rate,15.21,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4124.74,88,,3299.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.67,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,15.21,4218.48,
LEVEL 1 UPPER/LOWER GI PROCEDURES,9140,CDM,750,RC,,,Outpatient,,,4866.88,2920.13,,4136.85,85,,3309.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1564.7,32.15,,1251.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3894.96,80.03,,3115.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4380.19,90,,3504.15,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1564.7,32.15,,1251.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4866.88,,,,Other,Not Separately reimbursable,1564.7,32.15,,1251.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4282.85,88,,3426.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1611.42,33.11,,1289.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1564.7,4380.19,
TNKASE 50MG : INJ,293455,CDM,636,RC,J3101,HCPCS,Outpatient,,,4933,2959.8,,4193.05,85,,3354.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1585.96,32.15,,1268.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3947.88,80.03,,3158.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,156.16,102,,,fee schedule,Pays at 102% of CMS APC rate,4439.7,90,,3551.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1585.96,32.15,,1268.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.16,100,,,fee schedule,Pays at 100% of CMS APC rate,1585.96,32.15,,1268.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4341.04,88,,3472.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1633.32,33.11,,1306.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1585.96,4439.7,
"LARYNGOSCOPY, FLEX FIBEROPTIC W/LESION R",1431578,CDM,450,RC,31578,HCPCS,Outpatient,,,5030,3018,,4275.5,85,,3420.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1617.15,32.15,,1293.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4025.51,80.03,,3220.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3195.99,102,,,fee schedule,Pays at 102% of CMS APC rate,4527,90,,3621.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1617.15,32.15,,1293.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3195.99,100,,,fee schedule,Pays at 100% of CMS APC rate,1617.15,32.15,,1293.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4426.4,88,,3541.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1665.43,33.11,,1332.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1617.15,4527,
REPAIR EXT TENDON HAND,1426410,CDM,450,RC,26410,HCPCS,Outpatient,,,5045.75,3027.45,,4288.89,85,,3431.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4038.11,80.03,,3230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,4541.18,90,,3632.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4440.26,88,,3552.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1670.65,33.11,,1336.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1622.21,4541.18,
REPAIR EXT TEND FINGER,1426418,CDM,450,RC,26418,HCPCS,Outpatient,,,5045.75,3027.45,,4288.89,85,,3431.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4038.11,80.03,,3230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,4541.18,90,,3632.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4440.26,88,,3552.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1670.65,33.11,,1336.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1622.21,4541.18,
SURG AMPUTATION PMALAN/JOINT,1426951,CDM,450,RC,26951,HCPCS,Outpatient,,,5045.75,3027.45,,4288.89,85,,3431.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4038.11,80.03,,3230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2853.74,102,,,fee schedule,Pays at 102% of CMS APC rate,4541.18,90,,3632.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2853.74,100,,,fee schedule,Pays at 100% of CMS APC rate,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4440.26,88,,3552.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1670.65,33.11,,1336.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1622.21,4541.18,
EXT TENDON REPAIR FOOT,1428208,CDM,450,RC,28208,HCPCS,Outpatient,,,5045.75,3027.45,,4288.89,85,,3431.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4038.11,80.03,,3230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2853.74,102,,,fee schedule,Pays at 102% of CMS APC rate,4541.18,90,,3632.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2853.74,100,,,fee schedule,Pays at 100% of CMS APC rate,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4440.26,88,,3552.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1670.65,33.11,,1336.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1622.21,4541.18,
TX TARSAL BONE FX W/MAN EA,1428455,CDM,450,RC,28455,HCPCS,Outpatient,,,5045.75,3027.45,,4288.89,85,,3431.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4038.11,80.03,,3230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,4541.18,90,,3632.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,1622.21,32.15,,1297.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4440.26,88,,3552.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1670.65,33.11,,1336.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1622.21,4541.18,
Removal of cataract with insertion of lens,110024,CDM,361,RC,66984,HCPCS,Outpatient,,,5054.63,3032.78,,4296.44,85,,3437.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1625.06,32.15,,1300.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4045.22,80.03,,3236.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2070.25,102,,,fee schedule,Pays at 102% of CMS APC rate,4549.17,90,,3639.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1625.06,32.15,,1300.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2070.25,100,,,fee schedule,Pays at 100% of CMS APC rate,1625.06,32.15,,1300.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4448.07,88,,3558.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1673.59,33.11,,1338.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1625.06,4549.17,
KNEE KIT SUBCHONDROPLASTY WITH SIDE-DEL,4999150,CDM,278,RC,C1776,HCPCS,Outpatient,,,5097.5,3058.5,,4332.88,85,,3466.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1638.85,32.15,,1311.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4079.53,80.03,,3263.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4587.75,90,,3670.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1638.85,32.15,,1311.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5097.5,,,,Other,Not Separately reimbursable,1638.85,32.15,,1311.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4485.8,88,,3588.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1687.78,33.11,,1350.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1638.85,4587.75,
LYR CLS SCLP TRNK AXL EXTR > 30.0 CM,1412037,CDM,450,RC,12037,HCPCS,Outpatient,,,5182.25,3109.35,,4404.91,85,,3523.93,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1666.09,32.15,,1332.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4147.35,80.03,,3317.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,4664.03,90,,3731.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1666.09,32.15,,1332.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,1666.09,32.15,,1332.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4560.38,88,,3648.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1715.84,33.11,,1372.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1666.09,4664.03,
IMPLANT FM COLLAMEND 6 X 8,4999030,CDM,278,RC,C1713,HCPCS,Outpatient,,,5545.5,3327.3,,4713.68,85,,3770.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1782.88,32.15,,1426.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4438.06,80.03,,3550.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4990.95,90,,3992.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1782.88,32.15,,1426.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5545.5,,,,Other,Not Separately reimbursable,1782.88,32.15,,1426.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4880.04,88,,3904.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1836.12,33.11,,1468.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1782.88,4990.95,
INVEGA SUSTENNA 156MG/ 1 ML IM INJ,304885,CDM,636,RC,J2426,HCPCS,Outpatient,,,5644.94,3386.96,,4798.2,85,,3838.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4517.65,80.03,,3614.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.62,102,,,fee schedule,Pays at 102% of CMS APC rate,5080.45,90,,4064.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.62,100,,,fee schedule,Pays at 100% of CMS APC rate,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,4967.55,88,,3974.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.34,5080.45,
ERCP,14300,CDM,750,RC,,,Outpatient,,,5699.25,3419.55,,4844.36,85,,3875.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1832.31,32.15,,1465.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4561.11,80.03,,3648.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5129.33,90,,4103.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1832.31,32.15,,1465.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5699.25,,,,Other,Not Separately reimbursable,1832.31,32.15,,1465.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5015.34,88,,4012.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1887.02,33.11,,1509.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1832.31,5129.33,
KIT LEAD TINED 28CM,4999926,CDM,278,RC,C1883,HCPCS,Outpatient,,,5855.25,3513.15,,4976.96,85,,3981.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1882.46,32.15,,1505.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4685.96,80.03,,3748.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5269.73,90,,4215.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1882.46,32.15,,1505.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5855.25,,,,Other,Not Separately reimbursable,1882.46,32.15,,1505.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5152.62,88,,4122.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1938.67,33.11,,1550.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1882.46,5269.73,
KIT LEAD TINED 41CM,4999928,CDM,278,RC,C1883,HCPCS,Outpatient,,,5855.25,3513.15,,4976.96,85,,3981.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1882.46,32.15,,1505.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4685.96,80.03,,3748.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5269.73,90,,4215.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1882.46,32.15,,1505.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5855.25,,,,Other,Not Separately reimbursable,1882.46,32.15,,1505.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5152.62,88,,4122.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1938.67,33.11,,1550.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1882.46,5269.73,
KIT LEAD TINED 33CM,4999927,CDM,278,RC,C1883,HCPCS,Outpatient,,,5857.75,3514.65,,4979.09,85,,3983.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1883.27,32.15,,1506.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4687.96,80.03,,3750.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5271.98,90,,4217.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1883.27,32.15,,1506.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5857.75,,,,Other,Not Separately reimbursable,1883.27,32.15,,1506.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5154.82,88,,4123.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1939.5,33.11,,1551.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1883.27,5271.98,
KIT ANKLE FIXATOR X CALIBUR,4999014,CDM,270,RC,,,Outpatient,,,5868,3520.8,,4987.8,85,,3990.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1886.56,32.15,,1509.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4696.16,80.03,,3756.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5281.2,90,,4224.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1886.56,32.15,,1509.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5868,,,,Other,Not Separately reimbursable,1886.56,32.15,,1509.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5163.84,88,,4131.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1942.89,33.11,,1554.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1886.56,5281.2,
LEVEL 4 GYNOCOLOGIC PROCEDURE,9420,CDM,790,RC,,,Outpatient,,,5878.75,3527.25,,4996.94,85,,3997.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1890.02,32.15,,1512.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4704.76,80.03,,3763.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5290.88,90,,4232.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1890.02,32.15,,1512.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5878.75,,,,Other,Not Separately reimbursable,1890.02,32.15,,1512.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5173.3,88,,4138.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1946.45,33.11,,1557.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1890.02,5290.88,
INSERT INTRAPERITONEAL CATH FOR DIALYS,1449420,CDM,450,RC,49421,HCPCS,Outpatient,,,5923.25,3553.95,,5034.76,85,,4027.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1904.32,32.15,,1523.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4740.38,80.03,,3792.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3395.65,102,,,fee schedule,Pays at 102% of CMS APC rate,5330.93,90,,4264.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1904.32,32.15,,1523.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3395.65,100,,,fee schedule,Pays at 100% of CMS APC rate,1904.32,32.15,,1523.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5212.46,88,,4169.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1961.19,33.11,,1568.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1904.32,5330.93,
LEVEL 3 LOWER GI PROCEDURES,9330,CDM,750,RC,,,Outpatient,,,5991.5,3594.9,,5092.78,85,,4074.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1926.27,32.15,,1541.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4795,80.03,,3836,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5392.35,90,,4313.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1926.27,32.15,,1541.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5991.5,,,,Other,Not Separately reimbursable,1926.27,32.15,,1541.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5272.52,88,,4218.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1983.79,33.11,,1587.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1926.27,5392.35,
MASTECTOMY 1ST 30 MIN,110020,CDM,360,RC,,,Outpatient,,,6014.5,3608.7,,5112.33,85,,4089.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1933.66,32.15,,1546.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4813.4,80.03,,3850.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5413.05,90,,4330.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1933.66,32.15,,1546.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6014.5,,,,Other,Not Separately reimbursable,1933.66,32.15,,1546.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5292.76,88,,4234.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1991.4,33.11,,1593.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1933.66,5413.05,
LEVEL 3 EXCISION/BIOPSY/INCIS & DRAINAGE,9355,CDM,790,RC,,,Outpatient,,,6015.5,3609.3,,5113.18,85,,4090.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,1933.98,32.15,,1547.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,4814.2,80.03,,3851.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5413.95,90,,4331.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,1933.98,32.15,,1547.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6015.5,,,,Other,Not Separately reimbursable,1933.98,32.15,,1547.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5293.64,88,,4234.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,1991.73,33.11,,1593.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,1933.98,5413.95,
LEVEL 4 ENT,95164,CDM,360,RC,,,Outpatient,,,6286.3,3771.78,,5343.36,85,,4274.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2021.05,32.15,,1616.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5030.93,80.03,,4024.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5657.67,90,,4526.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2021.05,32.15,,1616.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6286.3,,,,Other,Not Separately reimbursable,2021.05,32.15,,1616.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5531.94,88,,4425.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2081.39,33.11,,1665.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2021.05,5657.67,
LEVEL 3 VASCULAR PROCEDURES,9340,CDM,790,RC,,,Outpatient,,,6450,3870,,5482.5,85,,4386,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2073.68,32.15,,1658.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5161.94,80.03,,4129.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5805,90,,4644,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2073.68,32.15,,1658.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6450,,,,Other,Not Separately reimbursable,2073.68,32.15,,1658.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5676,88,,4540.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2135.6,33.11,,1708.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2073.68,5805,
LEVEL 4 AIRWAY ENDOSCOPY,9450,CDM,790,RC,,,Outpatient,,,6770,4062,,5754.5,85,,4603.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2176.56,32.15,,1741.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5418.03,80.03,,4334.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6093,90,,4874.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2176.56,32.15,,1741.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6770,,,,Other,Not Separately reimbursable,2176.56,32.15,,1741.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5957.6,88,,4766.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2241.55,33.11,,1793.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2176.56,6093,
DOLPHIX U-ROD PROCEDURE KIT,4900020,CDM,270,RC,,,Outpatient,,,6875,4125,,5843.75,85,,4675,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2210.31,32.15,,1768.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5502.06,80.03,,4401.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6187.5,90,,4950,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2210.31,32.15,,1768.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6875,,,,Other,Not Separately reimbursable,2210.31,32.15,,1768.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6050,88,,4840,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2276.31,33.11,,1821.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2210.31,6187.5,
LEVEL 4 UROLOGY,9400,CDM,790,RC,,,Outpatient,,,6986.25,4191.75,,5938.31,85,,4750.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2246.08,32.15,,1796.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5591.1,80.03,,4472.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6287.63,90,,5030.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2246.08,32.15,,1796.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6986.25,,,,Other,Not Separately reimbursable,2246.08,32.15,,1796.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6147.9,88,,4918.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2313.15,33.11,,1850.52,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2246.08,6287.63,
LEVEL 5 SKIN PROCEDURES,9500,CDM,790,RC,,,Outpatient,,,7013.25,4207.95,,5961.26,85,,4769.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2254.76,32.15,,1803.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5612.7,80.03,,4490.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6311.93,90,,5049.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2254.76,32.15,,1803.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7013.25,,,,Other,Not Separately reimbursable,2254.76,32.15,,1803.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6171.66,88,,4937.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2322.09,33.11,,1857.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2254.76,6311.93,
LEVEL 1 BREAST / LYMPHATIC SURGERY & REL,6150,CDM,360,RC,,,Outpatient,,,7058.75,4235.25,,5999.94,85,,4799.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2269.39,32.15,,1815.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5649.12,80.03,,4519.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6352.88,90,,5082.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2269.39,32.15,,1815.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7058.75,,,,Other,Not Separately reimbursable,2269.39,32.15,,1815.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6211.7,88,,4969.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2337.15,33.11,,1869.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2269.39,6352.88,
LEVEL 1 BREAST / LYMPHATIC SURGERY,9410,CDM,790,RC,,,Outpatient,,,7058.75,4235.25,,5999.94,85,,4799.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2269.39,32.15,,1815.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5649.12,80.03,,4519.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6352.88,90,,5082.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2269.39,32.15,,1815.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7058.75,,,,Other,Not Separately reimbursable,2269.39,32.15,,1815.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6211.7,88,,4969.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2337.15,33.11,,1869.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2269.39,6352.88,
LEVEL 3 UPPER GI PROCEDURES,9360,CDM,750,RC,,,Outpatient,,,7099,4259.4,,6034.15,85,,4827.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2282.33,32.15,,1825.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5681.33,80.03,,4545.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6389.1,90,,5111.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2282.33,32.15,,1825.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7099,,,,Other,Not Separately reimbursable,2282.33,32.15,,1825.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6247.12,88,,4997.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2350.48,33.11,,1880.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2282.33,6389.1,
OB GYN 1ST 30 MIN,110008,CDM,360,RC,,,Outpatient,,,7102.5,4261.5,,6037.13,85,,4829.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2283.45,32.15,,1826.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,5684.13,80.03,,4547.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6392.25,90,,5113.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2283.45,32.15,,1826.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7102.5,,,,Other,Not Separately reimbursable,2283.45,32.15,,1826.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6250.2,88,,5000.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2351.64,33.11,,1881.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2283.45,6392.25,
INTRAVENOUS IMMUNE GLOBULIN 20GM,299975,CDM,636,RC,J1459,HCPCS,Outpatient,,,7315,4389,,6217.75,85,,4974.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,5854.19,80.03,,4683.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.54,102,,,fee schedule,Pays at 102% of CMS APC rate,6583.5,90,,5266.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.54,100,,,fee schedule,Pays at 100% of CMS APC rate,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6437.2,88,,5149.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,47.59,6583.5,
ABDOMINAL/PERITONEAL/BILIARY OR RELATED,9600,CDM,790,RC,,,Outpatient,,,7532.75,4519.65,,6402.84,85,,5122.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2421.78,32.15,,1937.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6028.46,80.03,,4822.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6779.48,90,,5423.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2421.78,32.15,,1937.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7532.75,,,,Other,Not Separately reimbursable,2421.78,32.15,,1937.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6628.82,88,,5303.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2494.09,33.11,,1995.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2421.78,6779.48,
GLAUKOS EYE STENT,110029,CDM,361,RC,0191T,HCPCS,Outpatient,,,7636.65,4581.99,,6491.15,85,,5192.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2455.18,32.15,,1964.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6111.61,80.03,,4889.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6872.99,90,,5498.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2455.18,32.15,,1964.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7636.65,,,,Other,Not Separately reimbursable,2455.18,32.15,,1964.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6720.25,88,,5376.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2528.49,33.11,,2022.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2455.18,6872.99,
GONIOTMY WITH KAHOOK,110030,CDM,361,RC,65820,HCPCS,Outpatient,,,7636.65,4581.99,,6491.15,85,,5192.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2455.18,32.15,,1964.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6111.61,80.03,,4889.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3830.59,102,,,fee schedule,Pays at 102% of CMS APC rate,6872.99,90,,5498.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2455.18,32.15,,1964.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3830.59,100,,,fee schedule,Pays at 100% of CMS APC rate,2455.18,32.15,,1964.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6720.25,88,,5376.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2528.49,33.11,,2022.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2455.18,6872.99,
SANDOSTATIN (OCTREOTIDE) LAR DEPOT 30MG,296098,CDM,636,RC,J2353,HCPCS,Outpatient,,,7749.7,4649.82,,6587.25,85,,5269.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,207.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6202.08,80.03,,4961.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,211.3,102,,,fee schedule,Pays at 102% of CMS APC rate,6974.73,90,,5579.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,207.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,211.3,100,,,fee schedule,Pays at 100% of CMS APC rate,207.16,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6819.74,88,,5455.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,213.37,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,207.16,6974.73,
IMPLANT FM COLLAMEND 8 X 10,4999031,CDM,278,RC,C1713,HCPCS,Outpatient,,,8021,4812.6,,6817.85,85,,5454.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2578.75,32.15,,2063,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6419.21,80.03,,5135.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7218.9,90,,5775.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2578.75,32.15,,2063,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8021,,,,Other,Not Separately reimbursable,2578.75,32.15,,2063,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7058.48,88,,5646.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2655.75,33.11,,2124.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2578.75,7218.9,
INVEGA SUSTENNA 234MG/ 1.5ML IM INJ,304886,CDM,636,RC,J2426,HCPCS,Outpatient,,,8467.22,5080.33,,7197.14,85,,5757.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,6776.32,80.03,,5421.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,14.62,102,,,fee schedule,Pays at 102% of CMS APC rate,7620.5,90,,6096.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14.62,100,,,fee schedule,Pays at 100% of CMS APC rate,14.34,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7451.15,88,,5960.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,14.34,7620.5,
LEVEL 3 MUSCULOSKELATAL PROCEDURES,9350,CDM,790,RC,,,Outpatient,,,8555.63,5133.38,,7272.29,85,,5817.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2750.64,32.15,,2200.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6847.07,80.03,,5477.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7700.07,90,,6160.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2750.64,32.15,,2200.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8555.63,,,,Other,Not Separately reimbursable,2750.64,32.15,,2200.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7528.95,88,,6023.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2832.77,33.11,,2266.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2750.64,7700.07,
LEVEL 1 NEUROSTIM & RELATED PROCEDURE,9170,CDM,790,RC,,,Outpatient,,,8939.25,5363.55,,7598.36,85,,6078.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2873.97,32.15,,2299.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7154.08,80.03,,5723.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8045.33,90,,6436.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2873.97,32.15,,2299.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8939.25,,,,Other,Not Separately reimbursable,2873.97,32.15,,2299.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7866.54,88,,6293.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,2959.79,33.11,,2367.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2873.97,8045.33,
LITHOTRIPSY,110015,CDM,790,RC,,,Outpatient,,,9265,5559,,7875.25,85,,6300.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,2978.7,32.15,,2382.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7414.78,80.03,,5931.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8338.5,90,,6670.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,2978.7,32.15,,2382.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9265,,,,Other,Not Separately reimbursable,2978.7,32.15,,2382.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8153.2,88,,6522.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3067.64,33.11,,2454.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,2978.7,8338.5,
LEVEL 2 NEUROSTIM WITH IMPLANT,9285,CDM,360,RC,,,Outpatient,,,9397.75,5638.65,,7988.09,85,,6390.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3021.38,32.15,,2417.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7521.02,80.03,,6016.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8457.98,90,,6766.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3021.38,32.15,,2417.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9397.75,,,,Other,Not Separately reimbursable,3021.38,32.15,,2417.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8270.02,88,,6616.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3111.6,33.11,,2489.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3021.38,8457.98,
LEVEL 5 UROLOGY,9520,CDM,790,RC,,,Outpatient,,,9589.25,5753.55,,8150.86,85,,6520.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3082.94,32.15,,2466.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7674.28,80.03,,6139.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8630.33,90,,6904.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3082.94,32.15,,2466.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9589.25,,,,Other,Not Separately reimbursable,3082.94,32.15,,2466.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8438.54,88,,6750.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3175,33.11,,2540,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3082.94,8630.33,
RABIES (HYPERRAB) IMMUNE GLOBULIN 5ML,293412,CDM,636,RC,90375,HCPCS,Outpatient,,,9652.8,5791.68,,8204.88,85,,6563.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,277.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,7725.14,80.03,,6180.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,283.29,102,,,fee schedule,Pays at 102% of CMS APC rate,8687.52,90,,6950.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,277.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,283.29,100,,,fee schedule,Pays at 100% of CMS APC rate,277.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,8494.46,88,,6795.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,286.07,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,277.74,8687.52,
LEVEL 4 MUSCULOSKELATAL PROC IMPLANTABLE,9446,CDM,790,RC,,,Outpatient,,,10443.25,6265.95,,8876.76,85,,7101.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3357.5,32.15,,2686,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8357.73,80.03,,6686.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9398.93,90,,7519.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3357.5,32.15,,2686,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10443.25,,,,Other,Not Separately reimbursable,3357.5,32.15,,2686,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9190.06,88,,7352.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3457.76,33.11,,2766.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3357.5,9398.93,
LEVEL 5 GYNOCOLOGIC PROCEDURE,9530,CDM,790,RC,,,Outpatient,,,10639.75,6383.85,,9043.79,85,,7235.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3420.68,32.15,,2736.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8514.99,80.03,,6811.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9575.78,90,,7660.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3420.68,32.15,,2736.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10639.75,,,,Other,Not Separately reimbursable,3420.68,32.15,,2736.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9362.98,88,,7490.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3522.82,33.11,,2818.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3420.68,9575.78,
ELBOW REDUCTION/S ANES,1424800,CDM,450,RC,24800,HCPCS,Outpatient,,,10804.25,6482.55,,9183.61,85,,7346.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3473.57,32.15,,2778.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8646.64,80.03,,6917.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,6341.48,102,,,fee schedule,Pays at 102% of CMS APC rate,9723.83,90,,7779.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3473.57,32.15,,2778.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,6341.48,100,,,fee schedule,Pays at 100% of CMS APC rate,3473.57,32.15,,2778.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9507.74,88,,7606.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3577.29,33.11,,2861.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3473.57,9723.83,
LEVEL 4 VASCULAR PROCEDURES,9430,CDM,790,RC,,,Outpatient,,,11035.25,6621.15,,9379.96,85,,7503.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,3547.83,32.15,,2838.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,8831.51,80.03,,7065.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9931.73,90,,7945.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,3547.83,32.15,,2838.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11035.25,,,,Other,Not Separately reimbursable,3547.83,32.15,,2838.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9711.02,88,,7768.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,3653.77,33.11,,2923.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,3547.83,9931.73,
LEVEL 2 BREAST / LYMPHANTIC SURGERY & RE,9265,CDM,790,RC,,,Outpatient,,,12450,7470,,10582.5,85,,8466,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4002.68,32.15,,3202.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,9963.74,80.03,,7970.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11205,90,,8964,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4002.68,32.15,,3202.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12450,,,,Other,Not Separately reimbursable,4002.68,32.15,,3202.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10956,88,,8764.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4122.2,33.11,,3297.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4002.68,10956,
LITHOTRIPSY PROCEDURES,9200,CDM,790,RC,,,Outpatient,,,13687.75,8212.65,,11634.59,85,,9307.67,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4400.61,32.15,,3520.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,10954.31,80.03,,8763.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12318.98,90,,9855.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4400.61,32.15,,3520.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13687.75,,,,Other,Not Separately reimbursable,4400.61,32.15,,3520.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12045.22,88,,9636.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4532.01,33.11,,3625.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4400.61,12045.22,
GENERATOR PULSE IMPLANTABLE INTERSTIM,4999923,CDM,278,RC,C1767,HCPCS,Outpatient,,,14394.25,8636.55,,12235.11,85,,9788.09,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4627.75,32.15,,3702.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11519.72,80.03,,9215.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12954.83,90,,10363.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4627.75,32.15,,3702.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14394.25,,,,Other,Not Separately reimbursable,4627.75,32.15,,3702.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12666.94,88,,10133.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4765.94,33.11,,3812.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4627.75,12666.94,
INSERTION OF TEMP TRANS PACEMAKER,1433210,CDM,450,RC,33210,HCPCS,Outpatient,,,14435.25,8661.15,,12269.96,85,,9815.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4640.93,32.15,,3712.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11552.53,80.03,,9242.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7825.7,102,,,fee schedule,Pays at 102% of CMS APC rate,12991.73,90,,10393.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4640.93,32.15,,3712.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7825.7,100,,,fee schedule,Pays at 100% of CMS APC rate,4640.93,32.15,,3712.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12703.02,88,,10162.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4779.51,33.11,,3823.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4640.93,12703.02,
LEVEL 4 MUSCULOSKELATAL PROCEDURES,9445,CDM,790,RC,,,Outpatient,,,14505.5,8703.3,,12329.68,85,,9863.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4663.52,32.15,,3730.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11608.75,80.03,,9287,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13054.95,90,,10443.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4663.52,32.15,,3730.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14505.5,,,,Other,Not Separately reimbursable,4663.52,32.15,,3730.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12764.84,88,,10211.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4802.77,33.11,,3842.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4663.52,12764.84,
LEVEL 1 LAPAROSCOPY AND RELATED,9150,CDM,790,RC,,,Outpatient,,,14518.44,8711.06,,12340.67,85,,9872.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,4667.68,32.15,,3734.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,11619.11,80.03,,9295.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13066.6,90,,10453.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,4667.68,32.15,,3734.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14518.44,,,,Other,Not Separately reimbursable,4667.68,32.15,,3734.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12776.23,88,,10220.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,4807.06,33.11,,3845.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,4667.68,12776.23,
IMPLANTATION NEUROSTIM URINARY CONTROL,64581,CDM,360,RC,,,Outpatient,,,15670,9402,,13319.5,85,,10655.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5037.91,32.15,,4030.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,12540.7,80.03,,10032.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14103,90,,11282.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5037.91,32.15,,4030.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15670,,,,Other,Not Separately reimbursable,5037.91,32.15,,4030.33,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13789.6,88,,11031.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5188.34,33.11,,4150.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5037.91,13789.6,
LEVEL 6 GYNOCOLOGIC PROCEDURE,9620,CDM,360,RC,,,Outpatient,,,16267,9760.2,,13826.95,85,,11061.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5229.84,32.15,,4183.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,13018.48,80.03,,10414.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14640.3,90,,11712.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5229.84,32.15,,4183.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16267,,,,Other,Not Separately reimbursable,5229.84,32.15,,4183.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14314.96,88,,11451.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,5386,33.11,,4308.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5229.84,14314.96,
INTRAVENOUS IMMUNE GLOBULIN 40GM/400ML,299977,CDM,636,RC,J1459,HCPCS,Outpatient,,,16358,9814.8,,13904.3,85,,11123.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13091.31,80.03,,10473.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.54,102,,,fee schedule,Pays at 102% of CMS APC rate,14722.2,90,,11777.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.54,100,,,fee schedule,Pays at 100% of CMS APC rate,47.59,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,14395.04,88,,11516.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.02,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,47.59,14395.04,
GENERATOR PULSE IMPLANTABLE II INTERSTIM,4999924,CDM,278,RC,C1767,HCPCS,Outpatient,,,18297.75,10978.65,,15553.09,85,,12442.47,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,5882.73,32.15,,4706.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,14643.69,80.03,,11714.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16467.98,90,,13174.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,5882.73,32.15,,4706.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18297.75,,,,Other,Not Separately reimbursable,5882.73,32.15,,4706.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16102.02,88,,12881.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6058.39,33.11,,4846.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,5882.73,16102.02,
INSERT PACEMAKER,33216,CDM,360,RC,,,Outpatient,,,19070,11442,,16209.5,85,,12967.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6131.01,32.15,,4904.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15261.72,80.03,,12209.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17163,90,,13730.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6131.01,32.15,,4904.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19070,,,,Other,Not Separately reimbursable,6131.01,32.15,,4904.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16781.6,88,,13425.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6314.08,33.11,,5051.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6131.01,16781.6,
LEVEL 2 PACEMAKER AND SIMILAR PROCEDURES,9270,CDM,790,RC,,,Outpatient,,,19072,11443.2,,16211.2,85,,12968.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6131.65,32.15,,4905.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15263.32,80.03,,12210.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17164.8,90,,13731.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6131.65,32.15,,4905.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19072,,,,Other,Not Separately reimbursable,6131.65,32.15,,4905.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,16783.36,88,,13426.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6314.74,33.11,,5051.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6131.65,16783.36,
LEVEL 2 LAPAROSCOPY AND RELATED,9280,CDM,360,RC,,,Outpatient,,,19653.5,11792.1,,16705.48,85,,13364.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,6318.6,32.15,,5054.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,15728.7,80.03,,12582.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17688.15,90,,14150.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,6318.6,32.15,,5054.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,19653.5,,,,Other,Not Separately reimbursable,6318.6,32.15,,5054.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,17295.08,88,,13836.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,6507.27,33.11,,5205.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,6318.6,17295.08,
LEVEL 3 NEUROSTIMULATOR & RELATED PROCED,9390,CDM,790,RC,,,Outpatient,,,23546.25,14127.75,,20014.31,85,,16011.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,7570.12,32.15,,6056.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,18844.06,80.03,,15075.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21191.63,90,,16953.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,7570.12,32.15,,6056.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23546.25,,,,Other,Not Separately reimbursable,7570.12,32.15,,6056.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20720.7,88,,16576.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,7796.16,33.11,,6236.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,7570.12,20720.7,
LEVEL 3 PACEMAKER AND SIMILAR PROCEDURES,9370,CDM,790,RC,,,Outpatient,,,25223,15133.8,,21439.55,85,,17151.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8109.19,32.15,,6487.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20185.97,80.03,,16148.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22700.7,90,,18160.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8109.19,32.15,,6487.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25223,,,,Other,Not Separately reimbursable,8109.19,32.15,,6487.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22196.24,88,,17756.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8351.34,33.11,,6681.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8109.19,22196.24,
ACTIVASE (alteplase) 100MG/100ML,293416,CDM,636,RC,J2997,HCPCS,Outpatient,,,25344,15206.4,,21542.4,85,,17233.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8148.1,32.15,,6518.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20282.8,80.03,,16226.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,90.94,102,,,fee schedule,Pays at 102% of CMS APC rate,22809.6,90,,18247.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8148.1,32.15,,6518.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90.94,100,,,fee schedule,Pays at 100% of CMS APC rate,8148.1,32.15,,6518.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22302.72,88,,17842.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8391.4,33.11,,6713.12,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8148.1,22302.72,
LEVEL 5 MUSCULOSKELATAL PROCEDURES,9550,CDM,790,RC,,,Outpatient,,,26191.75,15715.05,,22262.99,85,,17810.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8420.65,32.15,,6736.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20961.26,80.03,,16769.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23572.58,90,,18858.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8420.65,32.15,,6736.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26191.75,,,,Other,Not Separately reimbursable,8420.65,32.15,,6736.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23048.74,88,,18438.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8672.09,33.11,,6937.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8420.65,23048.74,
DECALICIFICATION PROCEDURE TC PP,8831126,CDM,971,RC,88311,HCPCS,Outpatient,,,12.5,7.5,,10.63,85,,8.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,10,80.03,,8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12.5,,,,Other,Not Separately reimbursable,15.45,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,11,88,,8.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.91,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,10,15.45,
LEVEL I-SURG PATH GROSS EXAM ONLY TC PP,8830026,CDM,971,RC,88300,HCPCS,Outpatient,,,15,9,,12.75,85,,10.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,12,80.03,,9.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,13.5,90,,10.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,14.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,13.2,88,,10.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,14.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,12,14.3,
CYTOPATH SMERS OTH SRC SCR&INTERP TC PP,8816026,CDM,971,RC,88160,HCPCS,Outpatient,,,24,14.4,,20.4,85,,16.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,19.21,80.03,,15.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,21.6,90,,17.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,21.12,88,,16.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,19.21,46.13,
MM CAD DIAG EXAM,8977051,CDM,972,RC,,,Outpatient,,,25,15,,21.25,85,,17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,20.01,80.03,,16.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25,,,,Other,Not Separately reimbursable,8.04,32.15,,6.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,22,88,,17.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,8.28,33.11,,6.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,8.04,22.5,
Urine test,2188112,CDM,971,RC,88112,HCPCS,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.21,106.19,
Urine test,8811226,CDM,971,RC,88112,HCPCS,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,106.19,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.38,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.21,106.19,
CYTOPATH FNA  INTRP & REPRT TC PP,8817326,CDM,971,RC,88173,HCPCS,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,91.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.33,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,23.21,91.58,
VENIPUNCTURE < 3 OTHER VEIN,1936406,CDM,981,RC,36406,HCPCS,Outpatient,,,29,17.4,,24.65,85,,19.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,23.21,80.03,,18.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,20.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29,,,,Other,Not Separately reimbursable,9.32,32.15,,7.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,25.52,88,,20.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.6,33.11,,7.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.32,26.1,
LEVEL II-SURG PATH GROSS & MICRO TC PP,8830226,CDM,971,RC,88302,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,35.06,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,36.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.01,35.06,
Blood test to assist with diagnosis,8831326,CDM,971,RC,88313,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,44.91,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.26,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,24.01,44.91,
VASCULAR ACCESS,1936000,CDM,981,RC,36000,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
VENIPUNCTURE > 3 BY PHYSICIAN,1936410,CDM,981,RC,36410,HCPCS,Outpatient,,,30,18,,25.5,85,,20.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,24.01,80.03,,19.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,90,,21.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,30,,,,Other,Not Separately reimbursable,9.65,32.15,,7.72,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,26.4,88,,21.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,9.93,33.11,,7.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,9.65,27,
PATH CONS-SURG 1 TISS BLK-FRZ-1addtl frz,8833226,CDM,971,RC,88332,HCPCS,Outpatient,,,34.45,20.67,,29.28,85,,23.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,27.57,80.03,,22.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.01,90,,24.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,34.45,,,,Other,Not Separately reimbursable,37.53,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.32,88,,24.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,38.66,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,27.57,37.53,
STRAPPING TOES,1929550,CDM,981,RC,29550,HCPCS,Outpatient,,,36.25,21.75,,30.81,85,,24.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.65,32.15,,9.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.01,80.03,,23.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,32.63,90,,26.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.65,32.15,,9.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,11.65,32.15,,9.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,31.9,88,,25.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12,33.11,,9.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.65,32.63,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",8976000,CDM,972,RC,76000,HCPCS,Outpatient,,,37,22.2,,31.45,85,,25.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,29.61,80.03,,23.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,33.3,90,,26.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,11.9,32.15,,9.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.56,88,,26.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,12.25,33.11,,9.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,11.9,33.3,
LEVEL III-SURG PATH GROSS & MICRO TC PP,8830426,CDM,971,RC,88304,HCPCS,Outpatient,,,37.5,22.5,,31.88,85,,25.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,30.01,80.03,,24.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,33.75,90,,27,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,30.18,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,33,88,,26.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.09,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,30.01,33.75,
Blood test to assist with diagnosis,8831226,CDM,971,RC,88312,HCPCS,Outpatient,,,40,24,,34,85,,27.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.01,80.03,,25.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,36,90,,28.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,43.39,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,35.2,88,,28.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.69,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.01,43.39,
IHC  ADDITIONAL SINGLE AB TC PP,8834126,CDM,971,RC,88341,HCPCS,Outpatient,,,41,24.6,,34.85,85,,27.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.81,80.03,,26.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.9,90,,29.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,41,,,,Other,Not Separately reimbursable,57.38,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.08,88,,28.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.1,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.81,57.38,
MORPHOMTRIC ANALY TUMR IHC MANUAL TC PP,8836026,CDM,971,RC,88360,HCPCS,Outpatient,,,41,24.6,,34.85,85,,27.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.81,80.03,,26.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,36.9,90,,29.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,97.65,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,36.08,88,,28.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.58,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,32.81,97.65,
Radiologic examination of the ankle with 2 views,8973600,CDM,972,RC,73600,HCPCS,Outpatient,,,41,24.6,,34.85,85,,27.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,32.81,80.03,,26.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,36.9,90,,29.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,13.18,32.15,,10.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.08,88,,28.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,13.58,33.11,,10.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,13.18,36.9,
XRAY EXAM OF SPINE SINGLE VIEW,8972020,CDM,972,RC,72020,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
"Radiologic examination of the middle spine, 2 views",8972070,CDM,972,RC,72070,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
XRAY EXAM OF SHOULDER 1 VIEW,8973020,CDM,972,RC,73020,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
"Radiologic examination, elbow; 2 views",8973070,CDM,972,RC,73070,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
Radiologic examination of the finger(s),8973140,CDM,972,RC,73140,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
"Radiologic examination, foot; 2 views",8973620,CDM,972,RC,73620,HCPCS,Outpatient,,,46,27.6,,39.1,85,,31.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,36.81,80.03,,29.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,41.4,90,,33.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,14.79,32.15,,11.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.48,88,,32.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.23,33.11,,12.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.79,41.4,
"DEBRIDEMENT OF NAIL, ANY METHOD 1-5",1911720,CDM,981,RC,11720,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.4,33.11,,12.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.95,41.85,
TEMP TRANSCUT PACING,1992953,CDM,981,RC,92953,HCPCS,Outpatient,,,46.5,27.9,,39.53,85,,31.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,37.21,80.03,,29.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,563.84,102,,,fee schedule,Pays at 102% of CMS APC rate,41.85,90,,33.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,563.84,100,,,fee schedule,Pays at 100% of CMS APC rate,14.95,32.15,,11.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.92,88,,32.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.4,33.11,,12.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,14.95,41.85,
Radiologic examination of the forearm,8973090,CDM,972,RC,73090,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
Radiologic examination of the ankle with 3 views,8973610,CDM,972,RC,73610,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
Radiologic examination of the foot with 3 or more views,8973630,CDM,972,RC,73630,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
Radiologic examination of the toe(s),8973660,CDM,972,RC,73660,HCPCS,Outpatient,,,48,28.8,,40.8,85,,32.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,38.41,80.03,,30.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,43.2,90,,34.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,15.43,32.15,,12.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.24,88,,33.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,15.89,33.11,,12.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.43,43.2,
ARTERIAL PUNCTURE,1936600,CDM,981,RC,36600,HCPCS,Outpatient,,,48.75,29.25,,41.44,85,,33.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,15.67,32.15,,12.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,39.01,80.03,,31.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,43.88,90,,35.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,15.67,32.15,,12.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,15.67,32.15,,12.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.9,88,,34.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.14,33.11,,12.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,15.67,43.88,
IHC MULTIPLEX AB STAIN TC PP,8834326,CDM,971,RC,88344,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,99.31,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.29,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,40.02,99.31,
4 or more views,8971030,CDM,972,RC,71048,HCPCS,Outpatient,,,50,30,,42.5,85,,34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.02,80.03,,32.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,45,90,,36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,16.08,32.15,,12.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44,88,,35.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.56,33.11,,13.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.08,45,
EKG INTERPRETATION,28002,CDM,985,RC,93010,HCPCS,Outpatient,,,50.43,30.26,,42.87,85,,34.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.21,32.15,,12.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.36,80.03,,32.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.39,90,,36.31,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.21,32.15,,12.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.43,,,,Other,Not Separately reimbursable,16.21,32.15,,12.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.38,88,,35.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.7,33.11,,13.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.21,45.39,
XRAY EXAM OF SACROILIAC JOINTS <3 VIEWS,972200,CDM,972,RC,72200,HCPCS,Outpatient,,,50.97,30.58,,43.32,85,,34.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.39,32.15,,13.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,40.79,80.03,,32.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,45.87,90,,36.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.39,32.15,,13.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,16.39,32.15,,13.11,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.85,88,,35.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,16.88,33.11,,13.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.39,45.87,
VENIPUNCTURE < 3 SCALP VEIN,1936405,CDM,981,RC,36405,HCPCS,Outpatient,,,51.75,31.05,,43.99,85,,35.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,41.42,80.03,,33.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.58,90,,37.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.75,,,,Other,Not Separately reimbursable,16.64,32.15,,13.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.54,88,,36.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.13,33.11,,13.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,16.64,46.58,
XRAY EXAM OF NASAL BONE,8970160,CDM,972,RC,70160,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
XRAY EXAM OF SINUSES <3 VIEWS,8970210,CDM,972,RC,70210,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
XRAY EXAM OF NECK,8970360,CDM,972,RC,70360,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
XRAY OF STERNOCLAVICULAR JOINT 3 VIEW,8971130,CDM,972,RC,71130,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
"Radiologic examination of the middle spine, 3 views",8972072,CDM,972,RC,72072,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
XRAY EXAM OF SACROILIAC JOINTS <3 VIEWS,8972200,CDM,972,RC,72200,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
XRAY EXAM OF SACROILIAC JOINTS 3 VIEWS,8972202,CDM,972,RC,72202,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
XRAY EXAM OF TAILBONE,8972220,CDM,972,RC,72220,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
XRAY EXAM OF SHOULDER BLADE,8973010,CDM,972,RC,73010,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
"Radiologic examination, elbow; 3 or more views",8973080,CDM,972,RC,73080,HCPCS,Outpatient,,,53,31.8,,45.05,85,,36.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,42.42,80.03,,33.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,47.7,90,,38.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.04,32.15,,13.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.64,88,,37.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.55,33.11,,14.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.04,47.7,
Single view,8971010,CDM,972,RC,71045,HCPCS,Outpatient,,,54,32.4,,45.9,85,,36.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.22,80.03,,34.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,48.6,90,,38.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.52,88,,38.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.88,33.11,,14.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.36,48.6,
Single view,8971035,CDM,972,RC,71045,HCPCS,Outpatient,,,54,32.4,,45.9,85,,36.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.22,80.03,,34.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,48.6,90,,38.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.52,88,,38.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.88,33.11,,14.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.36,48.6,
XRAY EXAM OF HUMERUS 2 VIEWS,8973060,CDM,972,RC,73060,HCPCS,Outpatient,,,54,32.4,,45.9,85,,36.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.22,80.03,,34.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,48.6,90,,38.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.52,88,,38.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.88,33.11,,14.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.36,48.6,
"XRAY EXAM OF HIP UNILATERAL, 1 VIEW",8973500,CDM,972,RC,73501,HCPCS,Outpatient,,,54,32.4,,45.9,85,,36.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.22,80.03,,34.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,48.6,90,,38.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.52,88,,38.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.88,33.11,,14.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.36,48.6,
XRAY EXAM OF THIGH,8973550,CDM,972,RC,73552,HCPCS,Outpatient,,,54,32.4,,45.9,85,,36.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,43.22,80.03,,34.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,48.6,90,,38.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,17.36,32.15,,13.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,47.52,88,,38.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,17.88,33.11,,14.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,17.36,48.6,
Test of tissues for diagnosis of abnormalities,8830526,CDM,971,RC,88305,HCPCS,Outpatient,,,55,33,,46.75,85,,37.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,44.02,80.03,,35.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,48.06,102,,,fee schedule,Pays at 102% of CMS APC rate,49.5,90,,39.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.06,100,,,fee schedule,Pays at 100% of CMS APC rate,65.88,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,48.4,88,,38.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.86,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,44.02,65.88,
XRAY EXAM OF RIBS UNILATERAL 2 VIEW,8971100,CDM,972,RC,71100,HCPCS,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.54,33.11,,14.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18,50.4,
EACH ADDITIONAL NAIL PLATE,1911732,CDM,981,RC,11732,HCPCS,Outpatient,,,56,33.6,,47.6,85,,38.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,44.82,80.03,,35.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.4,90,,40.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56,,,,Other,Not Separately reimbursable,18,32.15,,14.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.28,88,,39.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.54,33.11,,14.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18,50.4,
3 or more views,8972401,CDM,972,RC,73100,HCPCS,Outpatient,,,56.25,33.75,,47.81,85,,38.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.08,32.15,,14.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.02,80.03,,36.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,50.63,90,,40.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.08,32.15,,14.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,18.08,32.15,,14.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.5,88,,39.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.62,33.11,,14.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.08,50.63,
XRAY EXAM FACIAL BONES<3 VIEWS,8970140,CDM,972,RC,70140,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
Radiologic examination of the pelvis,8972170,CDM,972,RC,72170,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
Radiologic examination of the shoulder,8973030,CDM,972,RC,73030,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
Radiologic examination of the knee with 1 or 2 views,8973560,CDM,972,RC,73560,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
Radiologic examination of the heel,8973650,CDM,972,RC,73650,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
STRAPPING; SHOULDER (EG. VELPEAU),1929240,CDM,981,RC,29240,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
STRAPPING KNEE,1929530,CDM,981,RC,29530,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
STRAPPING ANKLE,1929540,CDM,981,RC,29540,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
"VENIPUNCTURE < 3 FEMORAL, JUGULAR",1936400,CDM,981,RC,36400,HCPCS,Outpatient,,,57,34.2,,48.45,85,,38.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,45.62,80.03,,36.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,90,,41.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57,,,,Other,Not Separately reimbursable,18.33,32.15,,14.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.16,88,,40.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,18.87,33.11,,15.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.33,51.3,
SYTO PATHOLOGY CERVICAL OR VAGINAL,8814126,CDM,971,RC,88160,HCPCS,Outpatient,,,57.45,34.47,,48.83,85,,39.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,45.98,80.03,,36.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,23.92,102,,,fee schedule,Pays at 102% of CMS APC rate,51.71,90,,41.37,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,23.92,100,,,fee schedule,Pays at 100% of CMS APC rate,46.13,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,50.56,88,,40.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.51,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,45.98,51.71,
XRAY EXAM OF PITUITARY SADDLE,8970240,CDM,972,RC,70240,HCPCS,Outpatient,,,58,34.8,,49.3,85,,39.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.42,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,52.2,90,,41.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.04,88,,40.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.2,33.11,,15.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.65,52.2,
Radiologic examination of one side of the chest/ribs,8971101,CDM,972,RC,71101,HCPCS,Outpatient,,,58,34.8,,49.3,85,,39.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,46.42,80.03,,37.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,52.2,90,,41.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,18.65,32.15,,14.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.04,88,,40.83,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.2,33.11,,15.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,18.65,52.2,
XRAY EXAM OF BREASTBONE 2 VIEWS,8971120,CDM,972,RC,71120,HCPCS,Outpatient,,,60,36,,51,85,,40.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.02,80.03,,38.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,54,90,,43.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,19.29,32.15,,15.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.8,88,,42.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,19.87,33.11,,15.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.29,54,
"2 views, front and back",8971020,CDM,972,RC,71046,HCPCS,Outpatient,,,61,36.6,,51.85,85,,41.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,48.82,80.03,,39.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,54.9,90,,43.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,19.61,32.15,,15.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.68,88,,42.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.2,33.11,,16.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.61,54.9,
CLEAN/DEBR/C ANES SMALL,1916010,CDM,981,RC,16010,HCPCS,Outpatient,,,61.5,36.9,,52.28,85,,41.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.77,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.22,80.03,,39.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.35,90,,44.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.77,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.5,,,,Other,Not Separately reimbursable,19.77,32.15,,15.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.12,88,,43.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.36,33.11,,16.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.77,55.35,
XRAY EXAM OF FISTULA,8976080,CDM,972,RC,76080,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.35,102,,,fee schedule,Pays at 102% of CMS APC rate,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.35,100,,,fee schedule,Pays at 100% of CMS APC rate,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.53,33.11,,16.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.93,55.8,
STRAPPING; ELBOW OR WRIST,1929260,CDM,981,RC,29260,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.53,33.11,,16.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.93,55.8,
STRAPPING; HAND OR FINGER,1929280,CDM,981,RC,29280,HCPCS,Outpatient,,,62,37.2,,52.7,85,,42.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,49.62,80.03,,39.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,55.8,90,,44.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,19.93,32.15,,15.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,54.56,88,,43.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.53,33.11,,16.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,19.93,55.8,
"HEMODIALYSIS, SINGLE EVAL",8790940,CDM,987,RC,90940,HCPCS,Outpatient,,,62.5,37.5,,53.13,85,,42.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,50.02,80.03,,40.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.25,90,,45,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.5,,,,Other,Not Separately reimbursable,20.09,32.15,,16.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55,88,,44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,20.69,33.11,,16.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.09,56.25,
XRAY EXAM OF SHOULDERS,8973050,CDM,972,RC,73050,HCPCS,Outpatient,,,64,38.4,,54.4,85,,43.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.22,80.03,,40.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,57.6,90,,46.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.32,88,,45.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.19,33.11,,16.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.58,57.6,
XRAY EXAM OF PELVIS OR HIPS INFANT/CHILD,8973540,CDM,972,RC,73502,HCPCS,Outpatient,,,64,38.4,,54.4,85,,43.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.22,80.03,,40.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,57.6,90,,46.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.32,88,,45.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.19,33.11,,16.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.58,57.6,
XRAY BILE DUCTS/PANCREAS THRU CATH,8974305,CDM,972,RC,47531,HCPCS,Outpatient,,,64,38.4,,54.4,85,,43.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.22,80.03,,40.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3395.67,102,,,fee schedule,Pays at 102% of CMS APC rate,57.6,90,,46.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3395.67,100,,,fee schedule,Pays at 100% of CMS APC rate,20.58,32.15,,16.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.32,88,,45.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.19,33.11,,16.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.58,57.6,
Up to 3 views,8973110,CDM,972,RC,73110,HCPCS,Outpatient,,,64.43,38.66,,54.77,85,,43.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,20.71,32.15,,16.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,51.56,80.03,,41.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,57.99,90,,46.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,20.71,32.15,,16.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,20.71,32.15,,16.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.7,88,,45.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.33,33.11,,17.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,20.71,57.99,
XRAY EXAM OF EYE SOCKETS,8970190,CDM,972,RC,70190,HCPCS,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
"Radiologic examination of the neck/spine, 2-3 views",8972040,CDM,972,RC,72040,HCPCS,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
XRAY EXAM OF THORACIC SPINE 4 VIEW,8972074,CDM,972,RC,72074,HCPCS,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
XRAY EXAM OF ABDOMEN,8974000,CDM,972,RC,74018,HCPCS,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
MM XRAY EXAM OF BREAST SPECIMEN,8976098,CDM,972,RC,76098,HCPCS,Outpatient,,,66,39.6,,56.1,85,,44.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,52.82,80.03,,42.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.35,102,,,fee schedule,Pays at 102% of CMS APC rate,59.4,90,,47.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.35,100,,,fee schedule,Pays at 100% of CMS APC rate,21.22,32.15,,16.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.08,88,,46.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,21.85,33.11,,17.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.22,59.4,
LEVEL 1,1999281,CDM,981,RC,99281,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.98,102,,,fee schedule,Pays at 102% of CMS APC rate,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.98,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.02,385,
LEVEL 1 W/ PROCEDURE,1999295,CDM,981,RC,99281,HCPCS,Outpatient,,,66.25,39.75,,56.31,85,,45.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.02,80.03,,42.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.98,102,,,fee schedule,Pays at 102% of CMS APC rate,59.63,90,,47.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.98,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.3,88,,46.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.02,385,
XRAY EXAM FACIAL BONES >3 VIEWS,8970150,CDM,972,RC,70150,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
3 views,8971021,CDM,972,RC,71047,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
X-ray of the lower spine 2-3 views,8972100,CDM,972,RC,72100,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
3 or more views,8973100,CDM,972,RC,73100,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
X-ray of the hand with 2 views,8973120,CDM,972,RC,73120,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
X-ray of the hand with 3 or more views,8973130,CDM,972,RC,73130,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
XRAY EXAM HIP UNILATERAL 2 VIEWS,8973510,CDM,972,RC,73502,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
XRAY EXAM HIP BILATERAL 2 VIEWS,8973520,CDM,972,RC,73521,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
Serial radiologic examination of the abdomen,8974022,CDM,972,RC,74022,HCPCS,Outpatient,,,67,40.2,,56.95,85,,45.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,53.62,80.03,,42.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,60.3,90,,48.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,21.54,32.15,,17.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,58.96,88,,47.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,22.18,33.11,,17.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,21.54,60.3,
Radiologic examination of the knee with 4 or more views,8973564,CDM,972,RC,73564,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.18,33.11,,18.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.51,63,
XRAY EXAM  ABDOMEN DECUBITUS &/DR ERECT,8974020,CDM,972,RC,74021,HCPCS,Outpatient,,,70,42,,59.5,85,,47.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,56.02,80.03,,44.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,63,90,,50.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,22.51,32.15,,18.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.6,88,,49.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.18,33.11,,18.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,22.51,63,
"XRAY EXAM OF EYE SOCKETS, MIN 4 VIEWS",8970200,CDM,972,RC,70200,HCPCS,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.84,33.11,,19.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.15,64.8,
XRAY EXAM OF SKULL < 4 VIEWS,8970250,CDM,972,RC,70250,HCPCS,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.84,33.11,,19.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.15,64.8,
XRAY EXAM OF JOINTS BILATERAL,8970330,CDM,972,RC,70330,HCPCS,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.84,33.11,,19.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.15,64.8,
XRAY EXAM OF THORACOLUMBAR AP/LAT 2 VIEW,8972080,CDM,972,RC,72080,HCPCS,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.84,33.11,,19.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.15,64.8,
XRAY EXAM OF HIP DURING SURGERY,8973530,CDM,972,RC,73502,HCPCS,Outpatient,,,72,43.2,,61.2,85,,48.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,57.62,80.03,,46.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,64.8,90,,51.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,23.15,32.15,,18.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.36,88,,50.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,23.84,33.11,,19.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.15,64.8,
XRAY EXAM OF MANDIBLE,8970100,CDM,972,RC,70100,HCPCS,Outpatient,,,74,44.4,,62.9,85,,50.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.22,80.03,,47.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,66.6,90,,53.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.12,88,,52.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.5,33.11,,19.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.79,66.6,
XRAY EXAM OF JAW,8970110,CDM,972,RC,70110,HCPCS,Outpatient,,,74,44.4,,62.9,85,,50.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.22,80.03,,47.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,66.6,90,,53.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.12,88,,52.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.5,33.11,,19.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.79,66.6,
"XRAY EXAM OF SINUSES, > 3 VIEWS",8970220,CDM,972,RC,70220,HCPCS,Outpatient,,,74,44.4,,62.9,85,,50.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,59.22,80.03,,47.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,66.6,90,,53.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,23.79,32.15,,19.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,65.12,88,,52.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.5,33.11,,19.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,23.79,66.6,
"Radiologic examination of the neck/spine, 4-5 views",8972050,CDM,972,RC,72050,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
"Radiologic examination of the neck/spine, 4-5 views",8972051,CDM,972,RC,72050,HCPCS,Outpatient,,,75,45,,63.75,85,,51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,60.02,80.03,,48.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,67.5,90,,54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,24.11,32.15,,19.29,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,66,88,,52.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,24.83,33.11,,19.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.11,67.5,
CYTOLOGY INTERPRETATION,8810826,CDM,971,RC,88108,HCPCS,Outpatient,,,76.95,46.17,,65.41,85,,52.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,61.58,80.03,,49.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,32.54,102,,,fee schedule,Pays at 102% of CMS APC rate,69.26,90,,55.41,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,32.54,100,,,fee schedule,Pays at 100% of CMS APC rate,45.74,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,67.72,88,,54.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,47.11,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,45.74,69.26,
XRAY EXAM OF RIBS BILATERAL 3 VIEW,8971110,CDM,972,RC,71110,HCPCS,Outpatient,,,77.11,46.27,,65.54,85,,52.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,24.79,32.15,,19.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,61.71,80.03,,49.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,69.4,90,,55.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,24.79,32.15,,19.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,24.79,32.15,,19.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.86,88,,54.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.53,33.11,,20.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,24.79,69.4,
"CHEST XRAY 2 VIEWS FRO &  LAT, W/OBLIQUE",8971022,CDM,972,RC,71022,HCPCS,Outpatient,,,78,46.8,,66.3,85,,53.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.42,80.03,,49.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.2,90,,56.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78,,,,Other,Not Separately reimbursable,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.64,88,,54.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.83,33.11,,20.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.08,70.2,
"X-ray of lower and sacral spine, minimum of 4 views",8972110,CDM,972,RC,72110,HCPCS,Outpatient,,,78,46.8,,66.3,85,,53.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.42,80.03,,49.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,70.2,90,,56.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.64,88,,54.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.83,33.11,,20.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.08,70.2,
Radiologic examination of the knee with 3 views,8973562,CDM,972,RC,73562,HCPCS,Outpatient,,,78,46.8,,66.3,85,,53.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,62.42,80.03,,49.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,70.2,90,,56.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,25.08,32.15,,20.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.64,88,,54.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,25.83,33.11,,20.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.08,70.2,
Removal of 6 or more nails,1911721,CDM,981,RC,11721,HCPCS,Outpatient,,,78.75,47.25,,66.94,85,,53.55,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.32,32.15,,20.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,63.02,80.03,,50.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,70.88,90,,56.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.32,32.15,,20.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,25.32,32.15,,20.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.3,88,,55.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.07,33.11,,20.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.32,70.88,
XRAY EXAM OF RIBS BILATERAL 4 VIEW,8971111,CDM,972,RC,71111,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
XRAY EXAM TRUNK SPINE,8972090,CDM,972,RC,72081,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
CHOLECYSTOGRAPHY,8974291,CDM,972,RC,74290,HCPCS,Outpatient,,,80,48,,68,85,,54.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,64.02,80.03,,51.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,72,90,,57.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,25.72,32.15,,20.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.4,88,,56.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.49,33.11,,21.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,25.72,72,
BLD SMEAR PERIPHRL INTRPT W REPORT,8506026,CDM,971,RC,85060,HCPCS,Outpatient,,,80.45,48.27,,68.38,85,,54.7,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,64.38,80.03,,51.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.41,90,,57.93,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,80.45,,,,Other,Not Separately reimbursable,25.97,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,70.8,88,,56.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,26.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,25.97,72.41,
MM XRAY EXAM OF MASTOIDS,8970130,CDM,972,RC,70130,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.81,33.11,,22.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.01,75.6,
XRAY EXAM OF MIDDLE EAR,8970134,CDM,972,RC,70134,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,482.35,102,,,fee schedule,Pays at 102% of CMS APC rate,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,482.35,100,,,fee schedule,Pays at 100% of CMS APC rate,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.81,33.11,,22.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.01,75.6,
XRAY EXAM OF SKULL > 4 VIEWS,8970260,CDM,972,RC,70260,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.81,33.11,,22.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.01,75.6,
XRAY URETHRA/BLADDER,8974455,CDM,972,RC,74455,HCPCS,Outpatient,,,84,50.4,,71.4,85,,57.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,67.23,80.03,,53.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,75.6,90,,60.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,27.01,32.15,,21.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,73.92,88,,59.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,27.81,33.11,,22.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.01,75.6,
XRAY FEMALE GENITAL TRACT,8974740,CDM,972,RC,74740,HCPCS,Outpatient,,,85,51,,72.25,85,,57.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.03,80.03,,54.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,76.5,90,,61.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,27.33,32.15,,21.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,74.8,88,,59.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.14,33.11,,22.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.33,76.5,
CLSD TX NASAL FX W/O MANIP,1921310,CDM,981,RC,21310,HCPCS,Outpatient,,,86,51.6,,73.1,85,,58.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,68.83,80.03,,55.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.4,90,,61.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86,,,,Other,Not Separately reimbursable,27.65,32.15,,22.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.68,88,,60.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.47,33.11,,22.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.65,77.4,
Ultrasound of fetus with limited views,8976815,CDM,972,RC,76815,HCPCS,Outpatient,,,86.3,51.78,,73.36,85,,58.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,27.75,32.15,,22.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,69.07,80.03,,55.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,77.67,90,,62.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,27.75,32.15,,22.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,27.75,32.15,,22.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,75.94,88,,60.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,28.57,33.11,,22.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,27.75,77.67,
MODIFIED BARIUM SWALLOW,8974230,CDM,972,RC,74230,HCPCS,Outpatient,,,88,52.8,,74.8,85,,59.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.43,80.03,,56.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,79.2,90,,63.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.44,88,,61.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.14,33.11,,23.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.29,79.2,
TISSUE ADHESIVE ONLY REPAIR,1910168,CDM,981,RC,G0168,HCPCS,Outpatient,,,88,52.8,,74.8,85,,59.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.43,80.03,,56.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.2,90,,63.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,,,,Other,Not Separately reimbursable,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.44,88,,61.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.14,33.11,,23.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.29,79.2,
WOUND ADHESIVE,1911041,CDM,981,RC,G0168,HCPCS,Outpatient,,,88,52.8,,74.8,85,,59.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,70.43,80.03,,56.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.2,90,,63.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88,,,,Other,Not Separately reimbursable,28.29,32.15,,22.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,77.44,88,,61.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.14,33.11,,23.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.29,79.2,
Radiologic examination of the lower leg,8973590,CDM,972,RC,73590,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
CONTRAST XRAY ESOPHAGUS,8974220,CDM,972,RC,74220,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
CONTRAST XRAY BLADDER 3 VIEWS,8974430,CDM,972,RC,74430,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",8977032,CDM,972,RC,77066,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,91.8,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.8,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
NM HEART WALL MOTION,8978478,CDM,974,RC,78478,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
NM HEART EF,8978480,CDM,974,RC,78480,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,90,,,,Other,Not Separately reimbursable,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
Removal of infected skin,1911000,CDM,981,RC,11000,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
"APPLICATION OF FINGER SPLINT, STATIC",1929130,CDM,981,RC,29130,HCPCS,Outpatient,,,90,54,,76.5,85,,61.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.03,80.03,,57.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,81,90,,64.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,28.94,32.15,,23.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.2,88,,63.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,29.8,33.11,,23.84,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,28.94,81,
XRAY EXAM OF C-SPINE (NECK) COMPLETE,8972052,CDM,972,RC,72052,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
CONTRAST XRAY URINARY TRACT ANTEGRADE,8974425,CDM,972,RC,74425,HCPCS,Outpatient,,,91,54.6,,77.35,85,,61.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,72.83,80.03,,58.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,81.9,90,,65.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,29.26,32.15,,23.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.08,88,,64.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,30.13,33.11,,24.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,29.26,81.9,
XRAY EXAM L-SPINE COMPLETE W/BENDING,8972112,CDM,972,RC,72114,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
XRAY EXAM L-SPINE COMPLETE W/BENDING,8972114,CDM,972,RC,72114,HCPCS,Outpatient,,,95,57,,80.75,85,,64.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.03,80.03,,60.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,85.5,90,,68.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,30.54,32.15,,24.43,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.6,88,,66.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.45,33.11,,25.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.54,85.5,
XRAY EXAM OF SALIVARY DUCT,8970390,CDM,972,RC,70390,HCPCS,Outpatient,,,96,57.6,,81.6,85,,65.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,30.86,32.15,,24.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,76.83,80.03,,61.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,86.4,90,,69.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,30.86,32.15,,24.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,30.86,32.15,,24.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.48,88,,67.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,31.79,33.11,,25.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,30.86,86.4,
MORPHOMTRIC ANALY TUMR IHC COMPUTE TC PP,8836126,CDM,971,RC,88361,HCPCS,Outpatient,,,98,58.8,,83.3,85,,66.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,78.43,80.03,,62.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,88.2,90,,70.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,122.28,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,86.24,88,,68.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,125.95,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,78.43,122.28,
NM THYROID IMAGING,8978010,CDM,974,RC,78012,HCPCS,Outpatient,,,98,58.8,,83.3,85,,66.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,31.51,32.15,,25.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,78.43,80.03,,62.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,88.2,90,,70.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,31.51,32.15,,25.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,31.51,32.15,,25.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.24,88,,68.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,32.45,33.11,,25.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,31.51,88.2,
"SUBSEQUENT INPT HOSPITAL CARE , LOW",8799231,CDM,987,RC,99231,HCPCS,Outpatient,,,100.08,60.05,,85.07,85,,68.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.18,32.15,,25.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.09,80.03,,64.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.07,90,,72.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.18,32.15,,25.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.08,,,,Other,Not Separately reimbursable,32.18,32.15,,25.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.07,88,,70.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.14,33.11,,26.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.18,90.07,
EVAC. SUBUNGUAL HEM,1911740,CDM,981,RC,11740,HCPCS,Outpatient,,,100.5,60.3,,85.43,85,,68.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.31,32.15,,25.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.43,80.03,,64.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,90.45,90,,72.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.31,32.15,,25.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,32.31,32.15,,25.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.44,88,,70.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.28,33.11,,26.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.31,90.45,
"SUBSEQUENT OBS HOSP CARE, LOW",8799224,CDM,960,RC,99224,HCPCS,Outpatient,,,100.96,60.58,,85.82,85,,68.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.46,32.15,,25.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.8,80.03,,64.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.86,90,,72.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.46,32.15,,25.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.96,,,,Other,Not Separately reimbursable,32.46,32.15,,25.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.84,88,,71.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.43,33.11,,26.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.46,90.86,
Radiologic examination of the collar bone,8973000,CDM,972,RC,73000,HCPCS,Outpatient,,,101,60.6,,85.85,85,,68.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.47,32.15,,25.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.83,80.03,,64.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.29,102,,,fee schedule,Pays at 102% of CMS APC rate,90.9,90,,72.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.47,32.15,,25.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.29,100,,,fee schedule,Pays at 100% of CMS APC rate,32.47,32.15,,25.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.88,88,,71.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.44,33.11,,26.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.47,90.9,
XRAY BILE DUCTS/PANCREAS,8974300,CDM,972,RC,74300,HCPCS,Outpatient,,,101,60.6,,85.85,85,,68.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.47,32.15,,25.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,80.83,80.03,,64.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.9,90,,72.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.47,32.15,,25.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101,,,,Other,Not Separately reimbursable,32.47,32.15,,25.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,88.88,88,,71.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.44,33.11,,26.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.47,90.9,
CLSD TX TEMPOROMANIBULAR DISLOC,1921480,CDM,981,RC,21480,HCPCS,Outpatient,,,101.5,60.9,,86.28,85,,69.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.63,32.15,,26.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.23,80.03,,64.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,91.35,90,,73.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.63,32.15,,26.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,32.63,32.15,,26.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.32,88,,71.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.61,33.11,,26.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.63,91.35,
HOLOGRAPH (3D) RECONSTRUCTION TOMOGRA,8976376,CDM,972,RC,76376,HCPCS,Outpatient,,,102,61.2,,86.7,85,,69.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.63,80.03,,65.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.8,90,,73.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102,,,,Other,Not Separately reimbursable,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.76,88,,71.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.77,33.11,,27.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.79,91.8,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",8977055,CDM,972,RC,77065,HCPCS,Outpatient,,,102,61.2,,86.7,85,,69.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.63,80.03,,65.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,79.83,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,91.8,90,,73.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,79.83,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.76,88,,71.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.77,33.11,,27.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.79,91.8,
Mammography of both breasts-2 or more views,8977057,CDM,972,RC,77067,HCPCS,Outpatient,,,102,61.2,,86.7,85,,69.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,81.63,80.03,,65.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,84.39,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,91.8,90,,73.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,84.39,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,32.79,32.15,,26.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.76,88,,71.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,33.77,33.11,,27.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,32.79,91.8,
Removal of ear wax from one or both ears,1969210,CDM,981,RC,69210,HCPCS,Outpatient,,,103.5,62.1,,87.98,85,,70.38,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,82.83,80.03,,66.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,55.1,102,,,fee schedule,Pays at 102% of CMS APC rate,93.15,90,,74.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,55.1,100,,,fee schedule,Pays at 100% of CMS APC rate,33.28,32.15,,26.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.08,88,,72.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,34.27,33.11,,27.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,33.28,93.15,
REMOVAL OF BIVALVING CAST,1929700,CDM,981,RC,29700,HCPCS,Outpatient,,,106.5,63.9,,90.53,85,,72.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,85.23,80.03,,68.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,95.85,90,,76.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,34.24,32.15,,27.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,93.72,88,,74.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.26,33.11,,28.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.24,95.85,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",8977056,CDM,972,RC,77066,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,101.75,102,,,fee schedule,Pays at 102% of CMS Physician Fee Schedule for Outpatient Setting,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.75,100,,,fee schedule,Pays at 100% of CMS Physician Fee Schedule for Outpatient Setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
US PVR MULTI ARTERIAL,8993923,CDM,972,RC,93923,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.41,102,,,fee schedule,Pays at 102% of CMS APC rate,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.41,100,,,fee schedule,Pays at 100% of CMS APC rate,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
US EXTREMITY BILAT ARTERIAL,8993925,CDM,972,RC,93925,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
US EXTREMITY UNILATERAL ARTERIAL,8993926,CDM,972,RC,93926,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
Complete bilateral study of the extremities,8993970,CDM,972,RC,93970,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
One sided or limited bilateral study,8993971,CDM,972,RC,93971,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
US RENAL  ARTERIAL,8993975,CDM,972,RC,93975,HCPCS,Outpatient,,,108,64.8,,91.8,85,,73.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,86.43,80.03,,69.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,97.2,90,,77.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,34.72,32.15,,27.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,95.04,88,,76.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,35.76,33.11,,28.61,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,34.72,97.2,
Draining or injecting medication into a small joint/bursa without ultrasound,1920600,CDM,981,RC,20600,HCPCS,Outpatient,,,111.75,67.05,,94.99,85,,75.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.93,32.15,,28.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.43,80.03,,71.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,100.58,90,,80.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.93,32.15,,28.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,35.93,32.15,,28.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.34,88,,78.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37,33.11,,29.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.93,100.58,
STRAPPING; UNNA BOOT,1929580,CDM,981,RC,29580,HCPCS,Outpatient,,,111.75,67.05,,94.99,85,,75.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,35.93,32.15,,28.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.43,80.03,,71.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,100.58,90,,80.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,35.93,32.15,,28.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,35.93,32.15,,28.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.34,88,,78.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37,33.11,,29.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,35.93,100.58,
Study of vessels on both sides of the head and neck,8993880,CDM,972,RC,93880,HCPCS,Outpatient,,,112,67.2,,95.2,85,,76.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,89.63,80.03,,71.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,100.8,90,,80.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,36.01,32.15,,28.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.56,88,,78.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.08,33.11,,29.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.01,100.8,
IRRIGATION OF BLADDER,1951700,CDM,981,RC,51700,HCPCS,Outpatient,,,113.75,68.25,,96.69,85,,77.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,91.03,80.03,,72.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,205.98,102,,,fee schedule,Pays at 102% of CMS APC rate,102.38,90,,81.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.98,100,,,fee schedule,Pays at 100% of CMS APC rate,36.57,32.15,,29.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,100.1,88,,80.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,37.66,33.11,,30.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,36.57,102.38,
Draining or injecting medication into a large joint/bursa without ultrasound,1920605,CDM,981,RC,20605,HCPCS,Outpatient,,,118,70.8,,100.3,85,,80.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,37.94,32.15,,30.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,94.44,80.03,,75.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,106.2,90,,84.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,37.94,32.15,,30.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,37.94,32.15,,30.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.84,88,,83.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,39.07,33.11,,31.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,37.94,106.2,
CONTRAST XRAY URINARY TRACT RETROGRADE,8974420,CDM,972,RC,74420,HCPCS,Outpatient,,,121,72.6,,102.85,85,,82.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,38.9,32.15,,31.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,96.84,80.03,,77.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,108.9,90,,87.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,38.9,32.15,,31.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,38.9,32.15,,31.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.48,88,,85.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.06,33.11,,32.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,38.9,108.9,
LEVEL V-SURG PATH GROSS & MICRO TC PP,8830726,CDM,971,RC,88307,HCPCS,Outpatient,,,122.5,73.5,,104.13,85,,83.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,98.04,80.03,,78.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,310.72,102,,,fee schedule,Pays at 102% of CMS APC rate,110.25,90,,88.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,310.72,100,,,fee schedule,Pays at 100% of CMS APC rate,133.3,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,107.8,88,,86.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.3,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,98.04,133.3,
APPLY SHORT ARM SPLINT,1929125,CDM,981,RC,29125,HCPCS,Outpatient,,,123.25,73.95,,104.76,85,,83.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.62,32.15,,31.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,98.64,80.03,,78.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,110.93,90,,88.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.62,32.15,,31.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,39.62,32.15,,31.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.46,88,,86.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,40.81,33.11,,32.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.62,110.93,
NM LIVER AND SPLEEN IMAGING,8978215,CDM,974,RC,78215,HCPCS,Outpatient,,,124,74.4,,105.4,85,,84.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.24,80.03,,79.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,111.6,90,,89.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,88,,87.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.06,33.11,,32.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.87,111.6,
"NM LUNG AEROSOL IMAGE, MULTIPLE",8978587,CDM,974,RC,78579,HCPCS,Outpatient,,,124,74.4,,105.4,85,,84.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.24,80.03,,79.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,111.6,90,,89.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,39.87,32.15,,31.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.12,88,,87.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.06,33.11,,32.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.87,111.6,
Injection of medication into a tendon or ligament,1920550,CDM,981,RC,20550,HCPCS,Outpatient,,,124.25,74.55,,105.61,85,,84.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,39.95,32.15,,31.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,99.44,80.03,,79.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,111.83,90,,89.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,39.95,32.15,,31.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,39.95,32.15,,31.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.34,88,,87.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,41.14,33.11,,32.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,39.95,111.83,
CUTDOWN VENIPUNCTURE > 1 Y/O,1936425,CDM,981,RC,36425,HCPCS,Outpatient,,,127.25,76.35,,108.16,85,,86.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,40.91,32.15,,32.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,101.84,80.03,,81.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,114.53,90,,91.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,40.91,32.15,,32.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,40.91,32.15,,32.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.98,88,,89.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.13,33.11,,33.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,40.91,114.53,
ANOSCOPY DIAGNOSTIC,1946600,CDM,981,RC,46600,HCPCS,Outpatient,,,128.25,76.95,,109.01,85,,87.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.23,32.15,,32.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.64,80.03,,82.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,115.43,90,,92.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.23,32.15,,32.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,41.23,32.15,,32.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,112.86,88,,90.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,42.46,33.11,,33.97,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.23,115.43,
LEVEL 2,1999282,CDM,981,RC,99282,HCPCS,Outpatient,,,129.5,77.7,,110.08,85,,88.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.64,80.03,,82.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,133.91,102,,,fee schedule,Pays at 102% of CMS APC rate,116.55,90,,93.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,133.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.96,88,,91.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.64,385,
LEVEL 2 W/ PROCEDURE,1999296,CDM,981,RC,99282,HCPCS,Outpatient,,,129.5,77.7,,110.08,85,,88.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,103.64,80.03,,82.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,133.91,102,,,fee schedule,Pays at 102% of CMS APC rate,116.55,90,,93.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,133.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.96,88,,91.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.64,385,
US OB FOLLOW-UP PER FETUS,8976816,CDM,972,RC,76816,HCPCS,Outpatient,,,130,78,,110.5,85,,88.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.04,80.03,,83.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,117,90,,93.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,41.8,32.15,,33.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.4,88,,91.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.04,33.11,,34.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.8,117,
NG TUBE INSERTION,1943752,CDM,981,RC,43752,HCPCS,Outpatient,,,130.5,78.3,,110.93,85,,88.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.44,80.03,,83.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,117.45,90,,93.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.84,88,,91.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.21,33.11,,34.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.96,117.45,
GASTRIC LAVAGE,1991105,CDM,981,RC,43752,HCPCS,Outpatient,,,130.5,78.3,,110.93,85,,88.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,104.44,80.03,,83.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,117.45,90,,93.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,41.96,32.15,,33.57,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,114.84,88,,91.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.21,33.11,,34.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,41.96,117.45,
CORNEAL FB REMOVAL,1965220,CDM,981,RC,65220,HCPCS,Outpatient,,,132.5,79.5,,112.63,85,,90.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,42.6,32.15,,34.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,106.04,80.03,,84.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,119.25,90,,95.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,42.6,32.15,,34.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,42.6,32.15,,34.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.6,88,,93.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,43.87,33.11,,35.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,42.6,119.25,
Fetal biophysical profile without non-stress test,8976819,CDM,972,RC,76819,HCPCS,Outpatient,,,134.5,80.7,,114.33,85,,91.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,107.64,80.03,,86.11,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,121.05,90,,96.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,43.24,32.15,,34.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.36,88,,94.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,44.53,33.11,,35.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.24,121.05,
US EXAM BREAST,8976645,CDM,972,RC,76641,HCPCS,Outpatient,,,136,81.6,,115.6,85,,92.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,108.84,80.03,,87.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,122.4,90,,97.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,43.72,32.15,,34.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.68,88,,95.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.03,33.11,,36.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.72,122.4,
SUPERFICIAL CONJUNCT FB REMOVAL,1965205,CDM,981,RC,65205,HCPCS,Outpatient,,,136.5,81.9,,116.03,85,,92.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.24,80.03,,87.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,122.85,90,,98.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,43.88,32.15,,35.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.12,88,,96.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.2,33.11,,36.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,43.88,122.85,
LEVEL VI-SURG PATH GROSS & MICRO TC PP,8830926,CDM,971,RC,88309,HCPCS,Outpatient,,,137,82.2,,116.45,85,,93.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,187.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,109.64,80.03,,87.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,123.3,90,,98.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,187.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,187.78,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,120.56,88,,96.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,193.41,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,109.64,187.78,
CONTRAST XRAY OF SHOULDER,8973040,CDM,972,RC,73040,HCPCS,Outpatient,,,137,82.2,,116.45,85,,93.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.64,80.03,,87.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,123.3,90,,98.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.56,88,,96.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.36,33.11,,36.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.05,123.3,
CONTRAST XRAY OF HIP,8973525,CDM,972,RC,73525,HCPCS,Outpatient,,,137,82.2,,116.45,85,,93.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.64,80.03,,87.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,123.3,90,,98.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.56,88,,96.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.36,33.11,,36.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.05,123.3,
CONTRAST XRAY OF KNEE JOINT,8973580,CDM,972,RC,73580,HCPCS,Outpatient,,,137,82.2,,116.45,85,,93.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,109.64,80.03,,87.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,123.3,90,,98.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,44.05,32.15,,35.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.56,88,,96.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.36,33.11,,36.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.05,123.3,
INITIAL IP CONSULT 20 MIN,1999251,CDM,981,RC,99251,HCPCS,Outpatient,,,137.5,82.5,,116.88,85,,93.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.04,80.03,,88.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.75,90,,99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.5,,,,Other,Not Separately reimbursable,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121,88,,96.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.53,33.11,,36.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.21,123.75,
INITIAL IP CONSULT 20 MIN W/ PROC,1999293,CDM,981,RC,99251,HCPCS,Outpatient,,,137.5,82.5,,116.88,85,,93.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.04,80.03,,88.03,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.75,90,,99,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.5,,,,Other,Not Separately reimbursable,44.21,32.15,,35.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121,88,,96.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.53,33.11,,36.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.21,123.75,
XRAY OF PACEMAKER INSERTION,8971090,CDM,972,RC,71090,HCPCS,Outpatient,,,138,82.8,,117.3,85,,93.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.37,32.15,,35.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,110.44,80.03,,88.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.2,90,,99.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.37,32.15,,35.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138,,,,Other,Not Separately reimbursable,44.37,32.15,,35.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,121.44,88,,97.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,45.69,33.11,,36.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.37,124.2,
CONTRAST XRAY OF WRIST,8973115,CDM,972,RC,73115,HCPCS,Outpatient,,,139,83.4,,118.15,85,,94.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.69,32.15,,35.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.24,80.03,,88.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.21,102,,,fee schedule,Pays at 102% of CMS APC rate,125.1,90,,100.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.69,32.15,,35.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.21,100,,,fee schedule,Pays at 100% of CMS APC rate,44.69,32.15,,35.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.32,88,,97.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.02,33.11,,36.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.69,125.1,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",1912001,CDM,981,RC,12001,HCPCS,Outpatient,,,139.75,83.85,,118.79,85,,95.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,44.93,32.15,,35.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.84,80.03,,89.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,125.78,90,,100.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,44.93,32.15,,35.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,44.93,32.15,,35.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,122.98,88,,98.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.27,33.11,,37.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,44.93,125.78,
WINDOWING OF CAST,1929730,CDM,981,RC,29730,HCPCS,Outpatient,,,141.75,85.05,,120.49,85,,96.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.57,32.15,,36.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.44,80.03,,90.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,127.58,90,,102.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.57,32.15,,36.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,45.57,32.15,,36.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.74,88,,99.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.93,33.11,,37.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.57,127.58,
NERVE BLOCK ONLY,1964450,CDM,981,RC,64450,HCPCS,Outpatient,,,141.75,85.05,,120.49,85,,96.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,45.57,32.15,,36.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,113.44,80.03,,90.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,127.58,90,,102.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,45.57,32.15,,36.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,45.57,32.15,,36.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,124.74,88,,99.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,46.93,33.11,,37.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,45.57,127.58,
TOUCH PREPARATION INITAL,8833326,CDM,971,RC,88333,HCPCS,Outpatient,,,144.2,86.52,,122.57,85,,98.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.4,80.03,,92.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,129.78,90,,103.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.9,88,,101.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,75.49,129.78,
TOUCH PREPARATION ADDITIONAL,8833426,CDM,971,RC,88333,HCPCS,Outpatient,,,144.2,86.52,,122.57,85,,98.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,115.4,80.03,,92.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,129.78,90,,103.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,75.49,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,126.9,88,,101.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.75,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,75.49,129.78,
INITIAL TX BURN 1ST DEGREE LOCAL TX ONLY,1916000,CDM,981,RC,16000,HCPCS,Outpatient,,,145,87,,123.25,85,,98.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.04,80.03,,92.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,130.5,90,,104.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,46.62,32.15,,37.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.6,88,,102.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.01,33.11,,38.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.62,130.5,
Draining or injecting medication into a major joint/bursa without ultrasound,1920610,CDM,981,RC,20610,HCPCS,Outpatient,,,146,87.6,,124.1,85,,99.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,116.84,80.03,,93.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,131.4,90,,105.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,46.94,32.15,,37.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,128.48,88,,102.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,48.34,33.11,,38.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,46.94,131.4,
Ultrasound of head and neck,8976536,CDM,972,RC,76536,HCPCS,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
US CHEST B-SCAN,8976604,CDM,972,RC,76604,HCPCS,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,8976870,CDM,972,RC,76705,HCPCS,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
Ultrasound of the scrotum,8976873,CDM,972,RC,76870,HCPCS,Outpatient,,,148,88.8,,125.8,85,,100.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,118.44,80.03,,94.75,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,133.2,90,,106.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,47.58,32.15,,38.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.24,88,,104.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49,33.11,,39.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.58,133.2,
"XRAY EXAM OF COLON, BE, W/ DR W/O KUB",8974270,CDM,972,RC,74270,HCPCS,Outpatient,,,149,89.4,,126.65,85,,101.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.24,80.03,,95.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,134.1,90,,107.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.12,88,,104.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.33,33.11,,39.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.9,134.1,
REMOV / BIVALVING ARM / LEG CAST,1929705,CDM,981,RC,29705,HCPCS,Outpatient,,,149,89.4,,126.65,85,,101.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.24,80.03,,95.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,229.98,102,,,fee schedule,Pays at 102% of CMS APC rate,134.1,90,,107.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,229.98,100,,,fee schedule,Pays at 100% of CMS APC rate,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.12,88,,104.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.33,33.11,,39.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.9,134.1,
REMOVAL FB EAR,1969200,CDM,981,RC,69200,HCPCS,Outpatient,,,149,89.4,,126.65,85,,101.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,119.24,80.03,,95.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,134.1,90,,107.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,47.9,32.15,,38.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.12,88,,104.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.33,33.11,,39.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,47.9,134.1,
Pathology test,8834226,CDM,971,RC,88342,HCPCS,Outpatient,,,149.16,89.5,,126.79,85,,101.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,119.37,80.03,,95.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,134.24,90,,107.39,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,71.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,131.26,88,,105.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.73,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,71.58,134.24,
FLUROSCOPE EXAM OVER 1 HOUR,8976001,CDM,972,RC,76001,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
CHANGE GASTROSTOMY TUBE,1943760,CDM,981,RC,43760,HCPCS,Outpatient,,,150,90,,127.5,85,,102,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.05,80.03,,96.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,108,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,32.15,,38.58,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132,88,,105.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,49.67,33.11,,39.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,48.23,135,
BRIEF SERVICE,1499281,CDM,981,RC,99281,HCPCS,Outpatient,,,150.75,90.45,,128.14,85,,102.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,120.65,80.03,,96.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,71.98,102,,,fee schedule,Pays at 102% of CMS APC rate,135.68,90,,108.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,71.98,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.66,88,,106.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120.65,385,
NM RED CELL SEQUESTRATION,8978140,CDM,974,RC,78140,HCPCS,Outpatient,,,154,92.4,,130.9,85,,104.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.51,32.15,,39.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.25,80.03,,98.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,138.6,90,,110.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.51,32.15,,39.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,49.51,32.15,,39.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.52,88,,108.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.99,33.11,,40.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.51,138.6,
NM KIDNEY IMAGING W/ FLOW,8978701,CDM,974,RC,78701,HCPCS,Outpatient,,,154,92.4,,130.9,85,,104.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,49.51,32.15,,39.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,123.25,80.03,,98.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,138.6,90,,110.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,49.51,32.15,,39.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,49.51,32.15,,39.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.52,88,,108.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,50.99,33.11,,40.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,49.51,138.6,
APPLY LONG LEG SPINT (THIGH TO ANK OR TO,1929505,CDM,981,RC,29505,HCPCS,Outpatient,,,156.25,93.75,,132.81,85,,106.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,50.23,32.15,,40.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,125.05,80.03,,100.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,140.63,90,,112.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,50.23,32.15,,40.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,50.23,32.15,,40.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.5,88,,110,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.73,33.11,,41.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,50.23,140.63,
APPLY SHORT LEG SPLINT (CALF TO FOOT),1929515,CDM,981,RC,29515,HCPCS,Outpatient,,,156.25,93.75,,132.81,85,,106.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,50.23,32.15,,40.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,125.05,80.03,,100.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,140.63,90,,112.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,50.23,32.15,,40.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,50.23,32.15,,40.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.5,88,,110,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,51.73,33.11,,41.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,50.23,140.63,
NM RENAL FLOW W/ PHARMACOLOGIC,8978708,CDM,974,RC,78708,HCPCS,Outpatient,,,159.5,95.7,,135.58,85,,108.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,127.65,80.03,,102.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,143.55,90,,114.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,51.28,32.15,,41.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.36,88,,112.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,52.81,33.11,,42.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.28,143.55,
CORNEAL FB REM W/ SLIT LAMP,1965222,CDM,981,RC,65222,HCPCS,Outpatient,,,161.5,96.9,,137.28,85,,109.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,51.92,32.15,,41.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,129.25,80.03,,103.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,145.35,90,,116.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,51.92,32.15,,41.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,51.92,32.15,,41.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.12,88,,113.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.47,33.11,,42.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,51.92,145.35,
INSERT ARTERIAL CATH PERCUTANEOUS,1936620,CDM,981,RC,36620,HCPCS,Outpatient,,,162.5,97.5,,138.13,85,,110.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.24,32.15,,41.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,130.05,80.03,,104.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.25,90,,117,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.24,32.15,,41.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.24,32.15,,41.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143,88,,114.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,53.8,33.11,,43.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.24,146.25,
EMBED CONJUNCT FB REMOVAL,1965210,CDM,981,RC,65210,HCPCS,Outpatient,,,164.5,98.7,,139.83,85,,111.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,52.89,32.15,,42.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,131.65,80.03,,105.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,148.05,90,,118.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,52.89,32.15,,42.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,52.89,32.15,,42.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.76,88,,115.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.47,33.11,,43.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,52.89,148.05,
MRI BREAST BIOPSY ADD LESION,8919086,CDM,972,RC,19086,HCPCS,Outpatient,,,165.25,99.15,,140.46,85,,112.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,53.13,32.15,,42.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,132.25,80.03,,105.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.73,90,,118.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,53.13,32.15,,42.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,53.13,32.15,,42.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,145.42,88,,116.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,54.71,33.11,,43.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,53.13,148.73,
NEEDLE LOCALIZATION BY XRAY,8976003,CDM,972,RC,77002,HCPCS,Outpatient,,,168,100.8,,142.8,85,,114.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.01,32.15,,43.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,134.45,80.03,,107.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.2,90,,120.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.01,32.15,,43.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.01,32.15,,43.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.84,88,,118.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.62,33.11,,44.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.01,151.2,
DRESS OR DEBRIDE BURN SMALL 1-2 DEGREE,1916020,CDM,981,RC,16020,HCPCS,Outpatient,,,168.75,101.25,,143.44,85,,114.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,135.05,80.03,,108.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,151.88,90,,121.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,54.25,32.15,,43.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.5,88,,118.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,55.87,33.11,,44.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,54.25,151.88,
1 Y/O CUTDOWN VENIPUNCTURE,1936420,CDM,981,RC,36420,HCPCS,Outpatient,,,171.75,103.05,,145.99,85,,116.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.22,32.15,,44.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.45,80.03,,109.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,154.58,90,,123.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.22,32.15,,44.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,55.22,32.15,,44.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.14,88,,120.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.87,33.11,,45.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.22,154.58,
PROCTOSIGMOIDOSCOPY,1945300,CDM,981,RC,45300,HCPCS,Outpatient,,,171.75,103.05,,145.99,85,,116.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.22,32.15,,44.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.45,80.03,,109.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,796.71,102,,,fee schedule,Pays at 102% of CMS APC rate,154.58,90,,123.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.22,32.15,,44.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.71,100,,,fee schedule,Pays at 100% of CMS APC rate,55.22,32.15,,44.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.14,88,,120.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.87,33.11,,45.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.22,154.58,
XRAY OF COLON AIR CONT W/ DR W/O GLUCAG,8974280,CDM,972,RC,74280,HCPCS,Outpatient,,,172,103.2,,146.2,85,,116.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.3,32.15,,44.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,137.65,80.03,,110.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,154.8,90,,123.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.3,32.15,,44.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,55.3,32.15,,44.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.36,88,,121.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,56.95,33.11,,45.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.3,154.8,
INITIAL IP CONSULT 40 MIN,1999252,CDM,981,RC,99252,HCPCS,Outpatient,,,172.5,103.5,,146.63,85,,117.3,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.46,32.15,,44.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.05,80.03,,110.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.25,90,,124.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.46,32.15,,44.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.46,32.15,,44.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,151.8,88,,121.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.11,33.11,,45.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.46,155.25,
US AMNIOCENTESIS,8976946,CDM,972,RC,76946,HCPCS,Outpatient,,,173,103.8,,147.05,85,,117.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.62,32.15,,44.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,138.45,80.03,,110.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.7,90,,124.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.62,32.15,,44.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.62,32.15,,44.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.24,88,,121.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.28,33.11,,45.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.62,155.7,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",1912011,CDM,981,RC,12011,HCPCS,Outpatient,,,174,104.4,,147.9,85,,118.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,55.94,32.15,,44.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.25,80.03,,111.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,156.6,90,,125.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,55.94,32.15,,44.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,55.94,32.15,,44.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.12,88,,122.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.61,33.11,,46.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,55.94,156.6,
"CLSD TX RIB FRACTURE, EA, UNCOMPLICATED",1921800,CDM,981,RC,,,Outpatient,,,174.5,104.7,,148.33,85,,118.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.1,32.15,,44.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.65,80.03,,111.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.05,90,,125.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.1,32.15,,44.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.1,32.15,,44.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.56,88,,122.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.78,33.11,,46.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.1,157.05,
Separation and removal of the entire nail plate or a portion of nail plate,1911730,CDM,981,RC,11730,HCPCS,Outpatient,,,175,105,,148.75,85,,119,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,140.05,80.03,,112.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,157.5,90,,126,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,56.26,32.15,,45.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154,88,,123.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,57.94,33.11,,46.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,56.26,157.5,
VENOGRAM EXTREMITY BILATERAL,8975822,CDM,972,RC,75822,HCPCS,Outpatient,,,178,106.8,,151.3,85,,121.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.23,32.15,,45.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,142.45,80.03,,113.96,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,160.2,90,,128.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.23,32.15,,45.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,57.23,32.15,,45.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,156.64,88,,125.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.94,33.11,,47.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.23,160.2,
NM MECKEL'S DIVERT EXAM,8978290,CDM,974,RC,78290,HCPCS,Outpatient,,,179,107.4,,152.15,85,,121.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.25,80.03,,114.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,161.1,90,,128.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.52,88,,126.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.27,33.11,,47.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.55,161.1,
NM HEART INFARCT IMAGE,8978466,CDM,974,RC,78466,HCPCS,Outpatient,,,179,107.4,,152.15,85,,121.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,143.25,80.03,,114.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,161.1,90,,128.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,57.55,32.15,,46.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.52,88,,126.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.27,33.11,,47.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.55,161.1,
CONTROL ANT / NASAL HEMORRHAGE,1930901,CDM,981,RC,30901,HCPCS,Outpatient,,,180,108,,153,85,,122.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,144.05,80.03,,115.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,162,90,,129.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,57.87,32.15,,46.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,158.4,88,,126.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,59.6,33.11,,47.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,57.87,162,
SIM LAC 2.6-5.0 CM,1912013,CDM,981,RC,12013,HCPCS,Outpatient,,,183.25,109.95,,155.76,85,,124.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,58.91,32.15,,47.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,146.65,80.03,,117.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,164.93,90,,131.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,58.91,32.15,,47.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,58.91,32.15,,47.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,161.26,88,,129.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.67,33.11,,48.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,58.91,164.93,
"SUBSEQUENT INPT HOSPITAL CARE , MOD",8799232,CDM,987,RC,99232,HCPCS,Outpatient,,,183.93,110.36,,156.34,85,,125.07,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.13,32.15,,47.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.2,80.03,,117.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.54,90,,132.43,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.13,32.15,,47.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.13,32.15,,47.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,161.86,88,,129.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,60.9,33.11,,48.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.13,165.54,
OBS HOSPITAL CARE DISCHARGE,8799217,CDM,960,RC,99217,HCPCS,Outpatient,,,184.8,110.88,,157.08,85,,125.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.41,32.15,,47.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.9,80.03,,118.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.32,90,,133.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.41,32.15,,47.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.41,32.15,,47.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.62,88,,130.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.19,33.11,,48.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.41,166.32,
"SUBSEQUENT OBS HOSP CARE, MOD",8799225,CDM,960,RC,99225,HCPCS,Outpatient,,,184.83,110.9,,157.11,85,,125.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.42,32.15,,47.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,147.92,80.03,,118.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.35,90,,133.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.42,32.15,,47.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.42,32.15,,47.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.65,88,,130.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.2,33.11,,48.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.42,166.35,
SIM LAC 2.6-7.5 CM,1912002,CDM,981,RC,12002,HCPCS,Outpatient,,,185.25,111.15,,157.46,85,,125.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.56,32.15,,47.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.26,80.03,,118.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,166.73,90,,133.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.56,32.15,,47.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,59.56,32.15,,47.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.02,88,,130.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.34,33.11,,49.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.56,166.73,
"HOSPITAL DISCHARGE , < 30 MINUTES",8799238,CDM,987,RC,99238,HCPCS,Outpatient,,,185.7,111.42,,157.85,85,,126.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.7,32.15,,47.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,148.62,80.03,,118.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.13,90,,133.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.7,32.15,,47.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.7,32.15,,47.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.42,88,,130.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.49,33.11,,49.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.7,167.13,
APPLY LONG ARM SPLINT,1929105,CDM,981,RC,29105,HCPCS,Outpatient,,,186.25,111.75,,158.31,85,,126.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.88,32.15,,47.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.06,80.03,,119.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,139.72,102,,,fee schedule,Pays at 102% of CMS APC rate,167.63,90,,134.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.88,32.15,,47.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,139.72,100,,,fee schedule,Pays at 100% of CMS APC rate,59.88,32.15,,47.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.9,88,,131.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.67,33.11,,49.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.88,167.63,
INTRAOSSEOUS IV,1936680,CDM,981,RC,36680,HCPCS,Outpatient,,,186.25,111.75,,158.31,85,,126.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,59.88,32.15,,47.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,149.06,80.03,,119.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,167.63,90,,134.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,59.88,32.15,,47.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,59.88,32.15,,47.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.9,88,,131.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,61.67,33.11,,49.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,59.88,167.63,
"HEMODIALYSIS, SINGLE EVAL",8790935,CDM,987,RC,90935,HCPCS,Outpatient,,,187.55,112.53,,159.42,85,,127.54,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,60.3,32.15,,48.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,150.1,80.03,,120.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,604.48,102,,,fee schedule,Pays at 102% of CMS APC rate,168.8,90,,135.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,60.3,32.15,,48.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,604.48,100,,,fee schedule,Pays at 100% of CMS APC rate,60.3,32.15,,48.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.04,88,,132.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,62.1,33.11,,49.68,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,60.3,168.8,
Complete ultrasound of the pelvis,89705,CDM,972,RC,76856,HCPCS,Outpatient,,,191,114.6,,162.35,85,,129.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.86,80.03,,122.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,171.9,90,,137.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.08,88,,134.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.24,33.11,,50.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.41,171.9,
Ultrasound of abdomen with all areas scanned,8976770,CDM,972,RC,76700,HCPCS,Outpatient,,,191,114.6,,162.35,85,,129.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.86,80.03,,122.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,171.9,90,,137.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.08,88,,134.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.24,33.11,,50.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.41,171.9,
Ultrasound of back wall of the abdomen with limited areas viewed,8976775,CDM,972,RC,76775,HCPCS,Outpatient,,,191,114.6,,162.35,85,,129.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.86,80.03,,122.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,171.9,90,,137.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.08,88,,134.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.24,33.11,,50.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.41,171.9,
Complete ultrasound of the pelvis,8976856,CDM,972,RC,76856,HCPCS,Outpatient,,,191,114.6,,162.35,85,,129.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,152.86,80.03,,122.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,171.9,90,,137.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,61.41,32.15,,49.13,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.08,88,,134.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.24,33.11,,50.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.41,171.9,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,8976705,CDM,972,RC,76705,HCPCS,Outpatient,,,192,115.2,,163.2,85,,130.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,61.73,32.15,,49.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,153.66,80.03,,122.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,172.8,90,,138.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,61.73,32.15,,49.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,61.73,32.15,,49.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.96,88,,135.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,63.57,33.11,,50.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,61.73,172.8,
DEBRIDEMENT SKIN PARTIAL THICKNESS,1911040,CDM,981,RC,11042,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,62.21,32.15,,49.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,64.07,33.11,,51.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,62.21,174.15,
"Emergency department visit, moderately severe problem",1999283,CDM,981,RC,99283,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,234.91,102,,,fee schedule,Pays at 102% of CMS APC rate,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154.86,385,
"Emergency department visit, moderately severe problem",1999297,CDM,981,RC,99283,HCPCS,Outpatient,,,193.5,116.1,,164.48,85,,131.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,154.86,80.03,,123.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,234.91,102,,,fee schedule,Pays at 102% of CMS APC rate,174.15,90,,139.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.28,88,,136.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154.86,385,
NM GASTRIC EMPTYING STUDY,8978264,CDM,974,RC,78264,HCPCS,Outpatient,,,197,118.2,,167.45,85,,133.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.66,80.03,,126.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,177.3,90,,141.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.36,88,,138.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.23,33.11,,52.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.34,177.3,
NM BONE IMAGING LTD AREA,8978300,CDM,974,RC,78300,HCPCS,Outpatient,,,197,118.2,,167.45,85,,133.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.66,80.03,,126.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,177.3,90,,141.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.36,88,,138.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.23,33.11,,52.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.34,177.3,
NM VENOUS THROMBOSIS IMAGING,8978457,CDM,974,RC,78457,HCPCS,Outpatient,,,197,118.2,,167.45,85,,133.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.66,80.03,,126.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,177.3,90,,141.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.36,88,,138.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.23,33.11,,52.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.34,177.3,
NM VENOUS THROMBOSIS IMAGING BILATERAL,8978458,CDM,974,RC,78458,HCPCS,Outpatient,,,197,118.2,,167.45,85,,133.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.66,80.03,,126.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,177.3,90,,141.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.36,88,,138.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.23,33.11,,52.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.34,177.3,
NM LUNG PERFUSION IMAGING,8978580,CDM,974,RC,78580,HCPCS,Outpatient,,,197,118.2,,167.45,85,,133.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,157.66,80.03,,126.13,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,177.3,90,,141.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,63.34,32.15,,50.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.36,88,,138.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,65.23,33.11,,52.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,63.34,177.3,
RETROGRADE URETHROGRAM,1951610,CDM,981,RC,51610,HCPCS,Outpatient,,,202.75,121.65,,172.34,85,,137.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,162.26,80.03,,129.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.48,90,,145.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.18,32.15,,52.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,178.42,88,,142.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.13,33.11,,53.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.18,182.48,
LIMITED SERVICE,1499282,CDM,981,RC,99282,HCPCS,Outpatient,,,204.5,122.7,,173.83,85,,139.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,163.66,80.03,,130.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,133.91,102,,,fee schedule,Pays at 102% of CMS APC rate,184.05,90,,147.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,133.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.96,88,,143.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,163.66,385,
NM PARATHYROID NUCLEAR IMAGING,8978070,CDM,974,RC,78070,HCPCS,Outpatient,,,205,123,,174.25,85,,139.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,65.91,32.15,,52.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,164.06,80.03,,131.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,184.5,90,,147.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,65.91,32.15,,52.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,65.91,32.15,,52.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,180.4,88,,144.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,67.88,33.11,,54.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,65.91,184.5,
BONE MARROW SMEAR INTERPRETATION,8509726,CDM,971,RC,85097,HCPCS,Outpatient,,,206.55,123.93,,175.57,85,,140.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,,,,,Other,Not Separately reimbursable,165.3,80.03,,132.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,744.44,102,,,fee schedule,Pays at 102% of CMS APC rate,185.9,90,,148.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744.44,100,,,fee schedule,Pays at 100% of CMS APC rate,,,,,Other,Not Separately reimbursable,181.76,88,,145.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,165.3,185.9,
PATH CONS-SURG 1 TISS BLK-FRZ-1 PROF,8833126,CDM,971,RC,88331,HCPCS,Outpatient,,,206.55,123.93,,175.57,85,,140.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165.3,80.03,,132.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,185.9,90,,148.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,181.76,88,,145.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,74.76,185.9,
CONSULT DURING SURGERY,8832926,CDM,971,RC,88331,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,74.76,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,74.76,186.3,
NM RENAL FLOW WITH AND W/O PHARMACOLOGIC,8978709,CDM,974,RC,78709,HCPCS,Outpatient,,,207,124.2,,175.95,85,,140.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,165.66,80.03,,132.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,186.3,90,,149.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,66.55,32.15,,53.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.16,88,,145.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,68.54,33.11,,54.83,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,66.55,186.3,
US GUIDANCE,8976942,CDM,972,RC,76942,HCPCS,Outpatient,,,210,126,,178.5,85,,142.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.52,32.15,,54.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.06,80.03,,134.45,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,90,,151.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.52,32.15,,54.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.52,32.15,,54.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,184.8,88,,147.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.53,33.11,,55.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.52,189,
NM HEPATOBILIARY IMAGING,8978223,CDM,974,RC,78227,HCPCS,Outpatient,,,211,126.6,,179.35,85,,143.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,168.86,80.03,,135.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,189.9,90,,151.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,67.84,32.15,,54.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.68,88,,148.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,69.86,33.11,,55.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,67.84,189.9,
REMOVAL IUD,1958301,CDM,981,RC,58301,HCPCS,Outpatient,,,212.25,127.35,,180.41,85,,144.33,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.24,32.15,,54.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,169.86,80.03,,135.89,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,279.89,102,,,fee schedule,Pays at 102% of CMS APC rate,191.03,90,,152.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.24,32.15,,54.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.89,100,,,fee schedule,Pays at 100% of CMS APC rate,68.24,32.15,,54.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,186.78,88,,149.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.28,33.11,,56.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.24,191.03,
INTERCOSTAL NERVE BLOCK; SINGLE,1964420,CDM,981,RC,64420,HCPCS,Outpatient,,,212.5,127.5,,180.63,85,,144.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.32,32.15,,54.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.06,80.03,,136.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,191.25,90,,153,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.32,32.15,,54.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,68.32,32.15,,54.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,187,88,,149.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.36,33.11,,56.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.32,191.25,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,8976800,CDM,972,RC,76801,HCPCS,Outpatient,,,214,128.4,,181.9,85,,145.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.26,80.03,,137.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,192.6,90,,154.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.32,88,,150.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.86,33.11,,56.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.8,192.6,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,8976801,CDM,972,RC,76801,HCPCS,Outpatient,,,214,128.4,,181.9,85,,145.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.26,80.03,,137.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,192.6,90,,154.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.32,88,,150.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.86,33.11,,56.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.8,192.6,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,8976805,CDM,972,RC,76805,HCPCS,Outpatient,,,214,128.4,,181.9,85,,145.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.26,80.03,,137.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,192.6,90,,154.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.32,88,,150.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.86,33.11,,56.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.8,192.6,
Transvaginal ultrasound of uterus,8976817,CDM,972,RC,76817,HCPCS,Outpatient,,,214,128.4,,181.9,85,,145.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.26,80.03,,137.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,192.6,90,,154.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.32,88,,150.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.86,33.11,,56.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.8,192.6,
Ultrasound of the pelvis through vagina,8976830,CDM,972,RC,76830,HCPCS,Outpatient,,,214,128.4,,181.9,85,,145.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,171.26,80.03,,137.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,192.6,90,,154.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,68.8,32.15,,55.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.32,88,,150.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,70.86,33.11,,56.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,68.8,192.6,
CT BONE DENSITY SPINE,8977078,CDM,972,RC,77078,HCPCS,Outpatient,,,215,129,,182.75,85,,146.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.12,32.15,,55.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.06,80.03,,137.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,83.28,102,,,fee schedule,Pays at 102% of CMS APC rate,193.5,90,,154.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.12,32.15,,55.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,83.28,100,,,fee schedule,Pays at 100% of CMS APC rate,69.12,32.15,,55.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.2,88,,151.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.19,33.11,,56.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.12,193.5,
REMOVAL CORNEAL RUST RING,1965435,CDM,981,RC,65435,HCPCS,Outpatient,,,215.25,129.15,,182.96,85,,146.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.2,32.15,,55.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.26,80.03,,137.81,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,836.6,102,,,fee schedule,Pays at 102% of CMS APC rate,193.73,90,,154.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.2,32.15,,55.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,836.6,100,,,fee schedule,Pays at 100% of CMS APC rate,69.2,32.15,,55.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.42,88,,151.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.27,33.11,,57.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.2,193.73,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",8978306,CDM,974,RC,78306,HCPCS,Outpatient,,,216,129.6,,183.6,85,,146.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.86,80.03,,138.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,194.4,90,,155.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.08,88,,152.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.52,33.11,,57.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.44,194.4,
"NM HEART MUSCLE BLOOD, SINGLE",8978460,CDM,974,RC,78451,HCPCS,Outpatient,,,216,129.6,,183.6,85,,146.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.86,80.03,,138.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,194.4,90,,155.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.08,88,,152.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.52,33.11,,57.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.44,194.4,
NM ABSCESS IMAGING LTD AREA,8978805,CDM,974,RC,78805,HCPCS,Outpatient,,,216,129.6,,183.6,85,,146.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.86,80.03,,138.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.4,90,,155.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,216,,,,Other,Not Separately reimbursable,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.08,88,,152.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.52,33.11,,57.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.44,194.4,
"NM ABSCESS IMAGING, WHOLE BODY",8978806,CDM,974,RC,78806,HCPCS,Outpatient,,,216,129.6,,183.6,85,,146.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.86,80.03,,138.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.4,90,,155.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,216,,,,Other,Not Separately reimbursable,69.44,32.15,,55.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,190.08,88,,152.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.52,33.11,,57.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.44,194.4,
THORACENTESIS WITH IMAGE GUIDANCE,8932555,CDM,972,RC,32555,HCPCS,Outpatient,,,217.25,130.35,,184.66,85,,147.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.87,80.03,,139.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,195.53,90,,156.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.18,88,,152.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.93,33.11,,57.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.85,195.53,
PARACENTESIS WITH IMAGE GUIDANCE,8949083,CDM,972,RC,32555,HCPCS,Outpatient,,,217.25,130.35,,184.66,85,,147.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.87,80.03,,139.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,195.53,90,,156.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,69.85,32.15,,55.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.18,88,,152.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,71.93,33.11,,57.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,69.85,195.53,
XRAY EXAM OF SMALL BOWEL,8974250,CDM,972,RC,74250,HCPCS,Outpatient,,,221,132.6,,187.85,85,,150.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.05,32.15,,56.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.87,80.03,,141.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,198.9,90,,159.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.05,32.15,,56.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,71.05,32.15,,56.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.48,88,,155.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.17,33.11,,58.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.05,198.9,
CONTRAST XRAY URINARY TRACT W WO KUB,8974400,CDM,972,RC,74400,HCPCS,Outpatient,,,221,132.6,,187.85,85,,150.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,71.05,32.15,,56.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,176.87,80.03,,141.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,198.9,90,,159.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,71.05,32.15,,56.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,71.05,32.15,,56.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,194.48,88,,155.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,73.17,33.11,,58.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,71.05,198.9,
IVP W/NEPHROTOMOGRAPHY,8974415,CDM,972,RC,74415,HCPCS,Outpatient,,,224,134.4,,190.4,85,,152.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.02,32.15,,57.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.27,80.03,,143.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,201.6,90,,161.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.02,32.15,,57.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,72.02,32.15,,57.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.12,88,,157.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.17,33.11,,59.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.02,201.6,
NERVE BLOCK TRIGEMINAL,1964400,CDM,981,RC,64400,HCPCS,Outpatient,,,224.5,134.7,,190.83,85,,152.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,72.18,32.15,,57.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,179.67,80.03,,143.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,260.64,102,,,fee schedule,Pays at 102% of CMS APC rate,202.05,90,,161.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,72.18,32.15,,57.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.64,100,,,fee schedule,Pays at 100% of CMS APC rate,72.18,32.15,,57.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.56,88,,158.05,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,74.33,33.11,,59.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,72.18,202.05,
XRAY UPR GI TRACT W/SMALL INTESTINE,8974245,CDM,972,RC,74245,HCPCS,Outpatient,,,228,136.8,,193.8,85,,155.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,73.3,32.15,,58.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,182.47,80.03,,145.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.2,90,,164.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,73.3,32.15,,58.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228,,,,Other,Not Separately reimbursable,73.3,32.15,,58.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,200.64,88,,160.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,75.49,33.11,,60.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,73.3,205.2,
SIM LAC 7.6-12.5 CM,1912004,CDM,981,RC,12004,HCPCS,Outpatient,,,231.75,139.05,,196.99,85,,157.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.51,32.15,,59.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.47,80.03,,148.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,208.58,90,,166.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.51,32.15,,59.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,74.51,32.15,,59.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.94,88,,163.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.73,33.11,,61.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.51,208.58,
VENOGRAM EXTREMITY UNILATERAL,8975820,CDM,972,RC,75820,HCPCS,Outpatient,,,232,139.2,,197.2,85,,157.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.67,80.03,,148.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.41,102,,,fee schedule,Pays at 102% of CMS APC rate,208.8,90,,167.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.41,100,,,fee schedule,Pays at 100% of CMS APC rate,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.16,88,,163.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.82,33.11,,61.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.59,208.8,
Transrectal ultrasound,8976872,CDM,972,RC,76872,HCPCS,Outpatient,,,232,139.2,,197.2,85,,157.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.67,80.03,,148.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,208.8,90,,167.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.16,88,,163.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.82,33.11,,61.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.59,208.8,
US EXTREMEMITY NON-VASCULAR,8976880,CDM,972,RC,76881,HCPCS,Outpatient,,,232,139.2,,197.2,85,,157.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.67,80.03,,148.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,208.8,90,,167.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.16,88,,163.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.82,33.11,,61.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.59,208.8,
US GROIN,8976881,CDM,972,RC,76881,HCPCS,Outpatient,,,232,139.2,,197.2,85,,157.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.67,80.03,,148.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,208.8,90,,167.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.16,88,,163.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.82,33.11,,61.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.59,208.8,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",8976882,CDM,972,RC,76882,HCPCS,Outpatient,,,232,139.2,,197.2,85,,157.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,185.67,80.03,,148.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,208.8,90,,167.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,74.59,32.15,,59.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.16,88,,163.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,76.82,33.11,,61.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,74.59,208.8,
INITIAL IP CONSULT 40 MIN W/ PROC,1999294,CDM,981,RC,99252,HCPCS,Outpatient,,,235.25,141.15,,199.96,85,,159.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.63,32.15,,60.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.27,80.03,,150.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.73,90,,169.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.63,32.15,,60.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.25,,,,Other,Not Separately reimbursable,75.63,32.15,,60.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.02,88,,165.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,77.89,33.11,,62.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.63,211.73,
CMPLX LAC TRK EACH ADDITIONAL 5 CM OR LE,1913102,CDM,981,RC,13102,HCPCS,Outpatient,,,236,141.6,,200.6,85,,160.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,75.87,32.15,,60.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,188.87,80.03,,151.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.4,90,,169.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,75.87,32.15,,60.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236,,,,Other,Not Separately reimbursable,75.87,32.15,,60.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.68,88,,166.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.14,33.11,,62.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,75.87,212.4,
SIM LAC 5.1- 7.5 CM,1912014,CDM,981,RC,12014,HCPCS,Outpatient,,,237,142.2,,201.45,85,,161.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.2,32.15,,60.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,189.67,80.03,,151.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,213.3,90,,170.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.2,32.15,,60.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,76.2,32.15,,60.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,208.56,88,,166.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,78.47,33.11,,62.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.2,213.3,
"NM GATED HEART, PLANAR, SINGLE",8978472,CDM,974,RC,78472,HCPCS,Outpatient,,,238.83,143.3,,203.01,85,,162.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,76.78,32.15,,61.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,191.14,80.03,,152.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,214.95,90,,171.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,76.78,32.15,,61.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,76.78,32.15,,61.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.17,88,,168.14,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.08,33.11,,63.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,76.78,214.95,
INCISION THROMBOSED HEMORRHOID EXT,1946083,CDM,981,RC,46083,HCPCS,Outpatient,,,240,144,,204,85,,163.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,77.16,32.15,,61.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,192.07,80.03,,153.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,205.98,102,,,fee schedule,Pays at 102% of CMS APC rate,216,90,,172.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,77.16,32.15,,61.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.98,100,,,fee schedule,Pays at 100% of CMS APC rate,77.16,32.15,,61.73,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.2,88,,168.96,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,79.46,33.11,,63.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,77.16,216,
US PREGNANT UTEREUS ADD'L FETUS,8976810,CDM,972,RC,76810,HCPCS,Outpatient,,,244,146.4,,207.4,85,,165.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,78.45,32.15,,62.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,195.27,80.03,,156.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.6,90,,175.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,78.45,32.15,,62.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,244,,,,Other,Not Separately reimbursable,78.45,32.15,,62.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.72,88,,171.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,80.79,33.11,,64.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,78.45,219.6,
XRAY UPR GI TRACT W/OR W/O DELAYED FILM,8974240,CDM,972,RC,74240,HCPCS,Outpatient,,,246,147.6,,209.1,85,,167.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.09,32.15,,63.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,196.87,80.03,,157.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,221.4,90,,177.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.09,32.15,,63.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,79.09,32.15,,63.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,216.48,88,,173.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.45,33.11,,65.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.09,221.4,
NM LUNG V/Q IMAGE SINGLE BREATH,8978584,CDM,974,RC,78582,HCPCS,Outpatient,,,247,148.2,,209.95,85,,167.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.41,32.15,,63.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.67,80.03,,158.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,222.3,90,,177.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.41,32.15,,63.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,79.41,32.15,,63.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.36,88,,173.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.78,33.11,,65.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.41,222.3,
LUMBAR PUNCTURE,1962270,CDM,981,RC,62270,HCPCS,Outpatient,,,247.25,148.35,,210.16,85,,168.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,79.49,32.15,,63.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,197.87,80.03,,158.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,617.72,102,,,fee schedule,Pays at 102% of CMS APC rate,222.53,90,,178.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,79.49,32.15,,63.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.72,100,,,fee schedule,Pays at 100% of CMS APC rate,79.49,32.15,,63.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.58,88,,174.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,81.86,33.11,,65.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,79.49,222.53,
CENTRAL VENOUS CATH PERCUTANEOUS <2 Y/O,1936488,CDM,981,RC,36488,HCPCS,Outpatient,,,250.75,150.45,,213.14,85,,170.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,80.62,32.15,,64.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,200.68,80.03,,160.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.68,90,,180.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,80.62,32.15,,64.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.75,,,,Other,Not Separately reimbursable,80.62,32.15,,64.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,220.66,88,,176.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,83.02,33.11,,66.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,80.62,225.68,
"INITIAL OBS HOSPITAL CARE, LOW",8799218,CDM,960,RC,99218,HCPCS,Outpatient,,,254.25,152.55,,216.11,85,,172.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.74,32.15,,65.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.48,80.03,,162.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228.83,90,,183.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.74,32.15,,65.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.25,,,,Other,Not Separately reimbursable,81.74,32.15,,65.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.74,88,,178.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.18,33.11,,67.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.74,228.83,
CONTROL ANT / NASAL HEM COMPLEX,1930903,CDM,981,RC,30903,HCPCS,Outpatient,,,254.5,152.7,,216.33,85,,173.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.68,80.03,,162.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.3,102,,,fee schedule,Pays at 102% of CMS APC rate,229.05,90,,183.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.3,100,,,fee schedule,Pays at 100% of CMS APC rate,81.82,32.15,,65.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.96,88,,179.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.26,33.11,,67.41,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.82,229.05,
XRAY EXAM SKELETAL SURVEY FOR METASTASES,8976062,CDM,972,RC,77075,HCPCS,Outpatient,,,254.87,152.92,,216.64,85,,173.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,81.94,32.15,,65.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,203.97,80.03,,163.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,229.38,90,,183.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,81.94,32.15,,65.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,81.94,32.15,,65.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.29,88,,179.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.39,33.11,,67.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,81.94,229.38,
NM BONE IMAGING 3 PHRASE STUDY,8978315,CDM,974,RC,78315,HCPCS,Outpatient,,,256,153.6,,217.6,85,,174.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,82.3,32.15,,65.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,204.88,80.03,,163.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,372.62,102,,,fee schedule,Pays at 102% of CMS APC rate,230.4,90,,184.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,82.3,32.15,,65.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.62,100,,,fee schedule,Pays at 100% of CMS APC rate,82.3,32.15,,65.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,225.28,88,,180.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,84.76,33.11,,67.81,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,82.3,230.4,
Incision and drainage of abscess; simple or single and complex or multiple,8710060,CDM,960,RC,10060,HCPCS,Outpatient,,,258.63,155.18,,219.84,85,,175.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.15,32.15,,66.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.98,80.03,,165.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,232.77,90,,186.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.15,32.15,,66.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,83.15,32.15,,66.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.59,88,,182.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.63,33.11,,68.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.15,232.77,
Incision and drainage of abscess; simple or single and complex or multiple,1910060,CDM,981,RC,10060,HCPCS,Outpatient,,,258.63,155.18,,219.84,85,,175.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.15,32.15,,66.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,206.98,80.03,,165.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,232.77,90,,186.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.15,32.15,,66.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,83.15,32.15,,66.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.59,88,,182.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.63,33.11,,68.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.15,232.77,
FNA IMMEDIATE ADEQUACY  PRO,8817226,CDM,971,RC,88172,HCPCS,Outpatient,,,258.75,155.25,,219.94,85,,175.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,56.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,207.08,80.03,,165.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,150.75,102,,,fee schedule,Pays at 102% of CMS APC rate,232.88,90,,186.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,56.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,150.75,100,,,fee schedule,Pays at 100% of CMS APC rate,56.58,100,,,fee schedule,Pays at 100% of GA Medicaid fee Schedule,227.7,88,,182.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,58.28,103,,,fee schedule,Pays at 103% of GA Medicaid fee Schedule,56.58,232.88,
"INITIAL INPT HOSPITAL CARE , LOW",8799221,CDM,987,RC,99221,HCPCS,Outpatient,,,259.65,155.79,,220.7,85,,176.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,83.48,32.15,,66.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,207.8,80.03,,166.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,233.69,90,,186.95,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,83.48,32.15,,66.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,259.65,,,,Other,Not Separately reimbursable,83.48,32.15,,66.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.49,88,,182.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,85.97,33.11,,68.78,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,83.48,233.69,
NM BONE IMAGING 3 D,8978320,CDM,974,RC,78320,HCPCS,Outpatient,,,263,157.8,,223.55,85,,178.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,84.55,32.15,,67.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,210.48,80.03,,168.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.7,90,,189.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,84.55,32.15,,67.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,263,,,,Other,Not Separately reimbursable,84.55,32.15,,67.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.44,88,,185.15,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.08,33.11,,69.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.55,236.7,
XRAY EXAM SKELETAL SURVEY INFANT,8976065,CDM,972,RC,77076,HCPCS,Outpatient,,,264,158.4,,224.4,85,,179.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,84.88,32.15,,67.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.28,80.03,,169.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,237.6,90,,190.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,84.88,32.15,,67.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,84.88,32.15,,67.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.32,88,,185.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.41,33.11,,69.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.88,237.6,
XRAY EXAM SKELETAL SURVEY,8977075,CDM,972,RC,77075,HCPCS,Outpatient,,,264,158.4,,224.4,85,,179.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,84.88,32.15,,67.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,211.28,80.03,,169.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,237.6,90,,190.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,84.88,32.15,,67.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,84.88,32.15,,67.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,232.32,88,,185.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.41,33.11,,69.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,84.88,237.6,
ANOSCOPY W/ FB REMOVAL,1946608,CDM,981,RC,46608,HCPCS,Outpatient,,,265,159,,225.25,85,,180.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.2,32.15,,68.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,212.08,80.03,,169.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,796.71,102,,,fee schedule,Pays at 102% of CMS APC rate,238.5,90,,190.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.2,32.15,,68.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.71,100,,,fee schedule,Pays at 100% of CMS APC rate,85.2,32.15,,68.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.2,88,,186.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.74,33.11,,70.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.2,238.5,
"SUBSEQUENT INPT HOSPITAL CARE , HIGH",8799233,CDM,987,RC,99233,HCPCS,Outpatient,,,265.08,159.05,,225.32,85,,180.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.22,32.15,,68.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,212.14,80.03,,169.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.57,90,,190.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.22,32.15,,68.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.08,,,,Other,Not Separately reimbursable,85.22,32.15,,68.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.27,88,,186.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.77,33.11,,70.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.22,238.57,
US RENAL BIOPSY,8950200,CDM,972,RC,50200,HCPCS,Outpatient,,,265.75,159.45,,225.89,85,,180.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.44,32.15,,68.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,212.68,80.03,,170.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,239.18,90,,191.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.44,32.15,,68.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,85.44,32.15,,68.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.86,88,,187.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,87.99,33.11,,70.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.44,239.18,
"SUBSEQUENT OBS HOSP CARE, HIGH",8799226,CDM,960,RC,99226,HCPCS,Outpatient,,,265.98,159.59,,226.08,85,,180.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.51,32.15,,68.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,212.86,80.03,,170.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.38,90,,191.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.51,32.15,,68.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.98,,,,Other,Not Separately reimbursable,85.51,32.15,,68.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.06,88,,187.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.07,33.11,,70.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.51,239.38,
CLSD TX NURSEMAID ELBOW W/MANIP,1924640,CDM,981,RC,24640,HCPCS,Outpatient,,,267,160.2,,226.95,85,,181.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,85.84,32.15,,68.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,213.68,80.03,,170.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,240.3,90,,192.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,85.84,32.15,,68.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,85.84,32.15,,68.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.96,88,,187.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.4,33.11,,70.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,85.84,240.3,
"HEMODIALYSIS, MULT EVAL",8790937,CDM,987,RC,90937,HCPCS,Outpatient,,,267.8,160.68,,227.63,85,,182.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.1,32.15,,68.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.32,80.03,,171.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.02,90,,192.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.1,32.15,,68.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,267.8,,,,Other,Not Separately reimbursable,86.1,32.15,,68.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.66,88,,188.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.67,33.11,,70.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.1,241.02,
MRA  HEAD W/O CONTRAST,8970544,CDM,972,RC,70544,HCPCS,Outpatient,,,268,160.8,,227.8,85,,182.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,214.48,80.03,,171.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,241.2,90,,192.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,86.16,32.15,,68.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.84,88,,188.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,88.73,33.11,,70.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.16,241.2,
MRA  OF NECK W/O CONTRAST,8970547,CDM,972,RC,70547,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.48,32.15,,69.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.48,32.15,,69.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,86.48,32.15,,69.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.07,33.11,,71.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.48,242.1,
MRA  OF NECK WITH CONTRAST,8970548,CDM,972,RC,70548,HCPCS,Outpatient,,,269,161.4,,228.65,85,,182.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,86.48,32.15,,69.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.28,80.03,,172.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,242.1,90,,193.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,86.48,32.15,,69.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,86.48,32.15,,69.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,236.72,88,,189.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,89.07,33.11,,71.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,86.48,242.1,
"Emergency department visit, moderately severe problem",1499283,CDM,981,RC,99283,HCPCS,Outpatient,,,269.75,161.85,,229.29,85,,183.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,215.88,80.03,,172.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,234.91,102,,,fee schedule,Pays at 102% of CMS APC rate,242.78,90,,194.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,234.91,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,237.38,88,,189.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,215.88,385,
CT UPPER  EXTREMITY  W/O DYE,8973200,CDM,972,RC,73200,HCPCS,Outpatient,,,272,163.2,,231.2,85,,184.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.68,80.03,,174.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,244.8,90,,195.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.36,88,,191.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.06,33.11,,72.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.45,244.8,
CTA UPPER  EXTREMITY  W/ DYE,8973206,CDM,972,RC,73206,HCPCS,Outpatient,,,272,163.2,,231.2,85,,184.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.68,80.03,,174.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,244.8,90,,195.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.36,88,,191.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.06,33.11,,72.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.45,244.8,
CT LOWER EXTREMITY W/  DYE,8973701,CDM,972,RC,73701,HCPCS,Outpatient,,,272,163.2,,231.2,85,,184.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.68,80.03,,174.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,244.8,90,,195.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,87.45,32.15,,69.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.36,88,,191.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.06,33.11,,72.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.45,244.8,
"CMPLX LAC CM SCALP,ARMS,LEGS EA ADD 5 CM",1913122,CDM,981,RC,13122,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.25,,,,Other,Not Separately reimbursable,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
"HOSPITAL DISCHARGE , >30 MINUTES",8799239,CDM,987,RC,99239,HCPCS,Outpatient,,,272.25,163.35,,231.41,85,,185.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,217.88,80.03,,174.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.03,90,,196.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.25,,,,Other,Not Separately reimbursable,87.53,32.15,,70.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.58,88,,191.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.14,33.11,,72.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.53,245.03,
CT scan of leg without dye,8973700,CDM,972,RC,73700,HCPCS,Outpatient,,,273,163.8,,232.05,85,,185.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,87.77,32.15,,70.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,218.48,80.03,,174.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,245.7,90,,196.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,87.77,32.15,,70.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,87.77,32.15,,70.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.24,88,,192.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,90.39,33.11,,72.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,87.77,245.7,
CLSD TX CLOSED IPJ DISLOC,1928660,CDM,981,RC,28660,HCPCS,Outpatient,,,279.5,167.7,,237.58,85,,190.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,89.86,32.15,,71.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.68,80.03,,178.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,251.55,90,,201.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,89.86,32.15,,71.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,89.86,32.15,,71.89,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,245.96,88,,196.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,92.54,33.11,,74.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,89.86,251.55,
CT OF HEAD/BRAIN W/DYE,8970460,CDM,972,RC,70460,HCPCS,Outpatient,,,281,168.6,,238.85,85,,191.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,90.34,32.15,,72.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,224.88,80.03,,179.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,252.9,90,,202.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,90.34,32.15,,72.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,90.34,32.15,,72.27,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.28,88,,197.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,93.04,33.11,,74.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,90.34,252.9,
CT scan head or brain without dye,8970450,CDM,972,RC,70450,HCPCS,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.03,33.11,,75.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.31,255.6,
CT Scan of the face and jaw without dye,8970486,CDM,972,RC,70486,HCPCS,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.03,33.11,,75.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.31,255.6,
MRI of leg without dye,8973718,CDM,972,RC,73718,HCPCS,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.03,33.11,,75.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.31,255.6,
MRI of lower extremity joint (knee/ankle) without dye,8973721,CDM,972,RC,73721,HCPCS,Outpatient,,,284,170.4,,241.4,85,,193.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.29,80.03,,181.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,255.6,90,,204.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,91.31,32.15,,73.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,249.92,88,,199.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.03,33.11,,75.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.31,255.6,
I&D OF BARTHOLIN ABSCESS,1956420,CDM,981,RC,56420,HCPCS,Outpatient,,,284.75,170.85,,242.04,85,,193.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,227.89,80.03,,182.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,170.77,102,,,fee schedule,Pays at 102% of CMS APC rate,256.28,90,,205.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,170.77,100,,,fee schedule,Pays at 100% of CMS APC rate,91.55,32.15,,73.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.58,88,,200.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.28,33.11,,75.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.55,256.28,
CRITICAL CARE EACH ADD'L 1/2 HOUR,8799292,CDM,960,RC,99292,HCPCS,Outpatient,,,284.9,170.94,,242.17,85,,193.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.6,32.15,,73.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.01,80.03,,182.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.41,90,,205.13,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.6,32.15,,73.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.9,,,,Other,Not Separately reimbursable,91.6,32.15,,73.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,250.71,88,,200.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.33,33.11,,75.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.6,256.41,
MONITORING FLUID PRESSURE FOR COMPARTMEN,1920950,CDM,981,RC,20950,HCPCS,Outpatient,,,285.75,171.45,,242.89,85,,194.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.69,80.03,,182.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,257.18,90,,205.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,251.46,88,,201.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.61,33.11,,75.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.87,257.18,
THORACENTESIS,1932000,CDM,981,RC,32554,HCPCS,Outpatient,,,285.75,171.45,,242.89,85,,194.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.69,80.03,,182.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,257.18,90,,205.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,251.46,88,,201.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.61,33.11,,75.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.87,257.18,
THORACENTESIS - PNEUMOTHORAX,1932002,CDM,981,RC,32554,HCPCS,Outpatient,,,285.75,171.45,,242.89,85,,194.31,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,228.69,80.03,,182.95,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,554.6,102,,,fee schedule,Pays at 102% of CMS APC rate,257.18,90,,205.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,554.6,100,,,fee schedule,Pays at 100% of CMS APC rate,91.87,32.15,,73.5,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,251.46,88,,201.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,94.61,33.11,,75.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,91.87,257.18,
CT CERVICAL WO CONTRAST,8972125,CDM,972,RC,72125,HCPCS,Outpatient,,,288,172.8,,244.8,85,,195.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.49,80.03,,184.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,259.2,90,,207.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.44,88,,202.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.36,33.11,,76.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.59,259.2,
CT CHEST  SPINE W/O DYE,8972128,CDM,972,RC,72128,HCPCS,Outpatient,,,288,172.8,,244.8,85,,195.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.49,80.03,,184.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,259.2,90,,207.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.44,88,,202.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.36,33.11,,76.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.59,259.2,
CT UPPER  EXTREMITY  W/ DYE,8973201,CDM,972,RC,73201,HCPCS,Outpatient,,,288,172.8,,244.8,85,,195.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.49,80.03,,184.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,259.2,90,,207.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.44,88,,202.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.36,33.11,,76.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.59,259.2,
CT LWR  EXTREMITY  W/ & W/O DYE,8973702,CDM,972,RC,73702,HCPCS,Outpatient,,,288,172.8,,244.8,85,,195.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,230.49,80.03,,184.39,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,259.2,90,,207.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,92.59,32.15,,74.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.44,88,,202.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.36,33.11,,76.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.59,259.2,
INTERCOSTAL NERVE BLOCK; MULTIPLE,1964421,CDM,981,RC,64421,HCPCS,Outpatient,,,288.75,173.25,,245.44,85,,196.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,92.83,32.15,,74.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,231.09,80.03,,184.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,816.98,102,,,fee schedule,Pays at 102% of CMS APC rate,259.88,90,,207.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,92.83,32.15,,74.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,816.98,100,,,fee schedule,Pays at 100% of CMS APC rate,92.83,32.15,,74.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,254.1,88,,203.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,95.61,33.11,,76.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,92.83,259.88,
WEDGE EXCISION-INGROWN NAIL,1911765,CDM,981,RC,11765,HCPCS,Outpatient,,,291.75,175.05,,247.99,85,,198.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,93.8,32.15,,75.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,233.49,80.03,,186.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,262.58,90,,210.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,93.8,32.15,,75.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,93.8,32.15,,75.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.74,88,,205.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,96.6,33.11,,77.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,93.8,262.58,
Vaginal delivery of placenta,1959414,CDM,981,RC,59414,HCPCS,Outpatient,,,294,176.4,,249.9,85,,199.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,235.29,80.03,,188.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2710.67,102,,,fee schedule,Pays at 102% of CMS APC rate,264.6,90,,211.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2710.67,100,,,fee schedule,Pays at 100% of CMS APC rate,94.52,32.15,,75.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.72,88,,206.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,97.34,33.11,,77.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,94.52,264.6,
SIM LAC 7.6-12.5 CM,1912015,CDM,981,RC,12015,HCPCS,Outpatient,,,298,178.8,,253.3,85,,202.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,95.81,32.15,,76.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,238.49,80.03,,190.79,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,268.2,90,,214.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,95.81,32.15,,76.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,95.81,32.15,,76.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,262.24,88,,209.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,98.67,33.11,,78.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,95.81,268.2,
MRI LOWER EXTREMITY  W&WO DYE,8973720,CDM,972,RC,73720,HCPCS,Outpatient,,,299,179.4,,254.15,85,,203.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,239.29,80.03,,191.43,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,269.1,90,,215.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,96.13,32.15,,76.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,263.12,88,,210.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99,33.11,,79.2,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.13,269.1,
MRI of lower extremity joint (knee/ankle) with dye,8973722,CDM,972,RC,73722,HCPCS,Outpatient,,,300,180,,255,85,,204,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.45,32.15,,77.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.09,80.03,,192.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,270,90,,216,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.45,32.15,,77.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,96.45,32.15,,77.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264,88,,211.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.33,33.11,,79.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.45,270,
MRI of lower extremity joint (knee/ankle) with and without dye,8973723,CDM,972,RC,73723,HCPCS,Outpatient,,,300,180,,255,85,,204,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.45,32.15,,77.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.09,80.03,,192.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,270,90,,216,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.45,32.15,,77.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,96.45,32.15,,77.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264,88,,211.2,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.33,33.11,,79.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.45,270,
PHLEBOTOMY,1999195,CDM,981,RC,99195,HCPCS,Outpatient,,,300.25,180.15,,255.21,85,,204.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.53,32.15,,77.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.29,80.03,,192.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,270.23,90,,216.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.53,32.15,,77.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,96.53,32.15,,77.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.22,88,,211.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.41,33.11,,79.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.53,270.23,
CT C-SPINE W/DYE,8972126,CDM,972,RC,72126,HCPCS,Outpatient,,,301,180.6,,255.85,85,,204.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.89,80.03,,192.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,270.9,90,,216.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.88,88,,211.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.66,33.11,,79.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.77,270.9,
CT EXTREMITY UPPER,8972129,CDM,972,RC,73200,HCPCS,Outpatient,,,301,180.6,,255.85,85,,204.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.89,80.03,,192.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,270.9,90,,216.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.88,88,,211.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.66,33.11,,79.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.77,270.9,
CT of abdomen without dye,8974150,CDM,972,RC,74150,HCPCS,Outpatient,,,301,180.6,,255.85,85,,204.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.89,80.03,,192.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,270.9,90,,216.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.88,88,,211.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.66,33.11,,79.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.77,270.9,
CT of abdomen with and without dye,8974170,CDM,972,RC,74170,HCPCS,Outpatient,,,301,180.6,,255.85,85,,204.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,240.89,80.03,,192.71,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,270.9,90,,216.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,96.77,32.15,,77.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,264.88,88,,211.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.66,33.11,,79.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.77,270.9,
SIMPLE LAC 12.6-20.0 CM,1912005,CDM,981,RC,12005,HCPCS,Outpatient,,,301.25,180.75,,256.06,85,,204.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,96.85,32.15,,77.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,241.09,80.03,,192.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,271.13,90,,216.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,96.85,32.15,,77.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,96.85,32.15,,77.48,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.1,88,,212.08,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,99.74,33.11,,79.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,96.85,271.13,
CT PELVIS W &  W/O DYE,8972194,CDM,972,RC,72194,HCPCS,Outpatient,,,303,181.8,,257.55,85,,206.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,97.41,32.15,,77.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,242.49,80.03,,193.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,272.7,90,,218.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,97.41,32.15,,77.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,97.41,32.15,,77.93,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,266.64,88,,213.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.32,33.11,,80.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,97.41,272.7,
CT L-SPINE  W/DYE,8972132,CDM,972,RC,72132,HCPCS,Outpatient,,,305,183,,259.25,85,,207.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.06,32.15,,78.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,244.09,80.03,,195.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,274.5,90,,219.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.06,32.15,,78.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,98.06,32.15,,78.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.4,88,,214.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.99,33.11,,80.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.06,274.5,
CT L-SPINE  W/DYE,8972133,CDM,972,RC,72132,HCPCS,Outpatient,,,305,183,,259.25,85,,207.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,98.06,32.15,,78.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,244.09,80.03,,195.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,274.5,90,,219.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,98.06,32.15,,78.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,98.06,32.15,,78.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.4,88,,214.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,100.99,33.11,,80.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,98.06,274.5,
NM LYMPH SYSTEM IMAGING,8978195,CDM,974,RC,78195,HCPCS,Outpatient,,,309,185.4,,262.65,85,,210.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.34,32.15,,79.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.29,80.03,,197.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,483.66,102,,,fee schedule,Pays at 102% of CMS APC rate,278.1,90,,222.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.34,32.15,,79.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,483.66,100,,,fee schedule,Pays at 100% of CMS APC rate,99.34,32.15,,79.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.92,88,,217.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.31,33.11,,81.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.34,278.1,
Image of the heart to assess perfusion,8978461,CDM,974,RC,78452,HCPCS,Outpatient,,,309,185.4,,262.65,85,,210.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,99.34,32.15,,79.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,247.29,80.03,,197.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,278.1,90,,222.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,99.34,32.15,,79.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,99.34,32.15,,79.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,271.92,88,,217.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,102.31,33.11,,81.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,99.34,278.1,
I & D PILONIDAL CYST,1910080,CDM,981,RC,10080,HCPCS,Outpatient,,,318.75,191.25,,270.94,85,,216.75,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.1,80.03,,204.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,286.88,90,,229.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,102.48,32.15,,81.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.5,88,,224.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.54,33.11,,84.43,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.48,286.88,
CT ORBIT/EAR/FOSSA W/O DYE,8970480,CDM,972,RC,70480,HCPCS,Outpatient,,,319,191.4,,271.15,85,,216.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.3,80.03,,204.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,287.1,90,,229.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.72,88,,224.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.62,33.11,,84.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.56,287.1,
MRI PELVIS W/ DYE,8972196,CDM,972,RC,72196,HCPCS,Outpatient,,,319,191.4,,271.15,85,,216.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.3,80.03,,204.24,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,287.1,90,,229.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,102.56,32.15,,82.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.72,88,,224.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.62,33.11,,84.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.56,287.1,
I & D REM FOREIGN BODY - SIMPLE,1910120,CDM,981,RC,10120,HCPCS,Outpatient,,,319.75,191.85,,271.79,85,,217.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.8,32.15,,82.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,255.9,80.03,,204.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,287.78,90,,230.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.8,32.15,,82.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,102.8,32.15,,82.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,281.38,88,,225.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.87,33.11,,84.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.8,287.78,
MRI CHEST W/ DYE,8971551,CDM,972,RC,71551,HCPCS,Outpatient,,,320,192,,272,85,,217.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,102.88,32.15,,82.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,256.1,80.03,,204.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,288,90,,230.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,102.88,32.15,,82.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,102.88,32.15,,82.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,281.6,88,,225.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,105.95,33.11,,84.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,102.88,288,
CT MAXILLOFACIAL  W /DYE,8970487,CDM,972,RC,70487,HCPCS,Outpatient,,,323,193.8,,274.55,85,,219.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,103.84,32.15,,83.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,258.5,80.03,,206.8,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,290.7,90,,232.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,103.84,32.15,,83.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,103.84,32.15,,83.07,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.24,88,,227.39,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,106.95,33.11,,85.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,103.84,290.7,
CT OF HEAD/BRAIN W/ & W/O DYE,8970470,CDM,972,RC,70470,HCPCS,Outpatient,,,326,195.6,,277.1,85,,221.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.9,80.03,,208.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,293.4,90,,234.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.88,88,,229.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.94,33.11,,86.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.81,293.4,
XRAYS FOR BONE AGE,8977072,CDM,972,RC,77072,HCPCS,Outpatient,,,326,195.6,,277.1,85,,221.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.9,80.03,,208.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.46,102,,,fee schedule,Pays at 102% of CMS APC rate,293.4,90,,234.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.46,100,,,fee schedule,Pays at 100% of CMS APC rate,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.88,88,,229.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.94,33.11,,86.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.81,293.4,
INTRANASAL REMOVAL OF FOREIGN BODY,1930300,CDM,981,RC,30300,HCPCS,Outpatient,,,326,195.6,,277.1,85,,221.68,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,260.9,80.03,,208.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,293.4,90,,234.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,104.81,32.15,,83.85,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.88,88,,229.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,107.94,33.11,,86.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,104.81,293.4,
CT scan of the thorax with dye,8971260,CDM,972,RC,71260,HCPCS,Outpatient,,,327,196.2,,277.95,85,,222.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.7,80.03,,209.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,294.3,90,,235.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,287.76,88,,230.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.27,33.11,,86.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.13,294.3,
CT scan of lower spine without dye,8972131,CDM,972,RC,72131,HCPCS,Outpatient,,,327,196.2,,277.95,85,,222.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.7,80.03,,209.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,294.3,90,,235.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,287.76,88,,230.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.27,33.11,,86.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.13,294.3,
CT of pelvis without dye,8972192,CDM,972,RC,72192,HCPCS,Outpatient,,,327,196.2,,277.95,85,,222.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.7,80.03,,209.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,294.3,90,,235.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,287.76,88,,230.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.27,33.11,,86.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.13,294.3,
"CT scan, pelvis, with contrast",8972193,CDM,972,RC,72193,HCPCS,Outpatient,,,327,196.2,,277.95,85,,222.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.7,80.03,,209.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,294.3,90,,235.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,287.76,88,,230.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.27,33.11,,86.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.13,294.3,
CT of abdomen with dye,8974160,CDM,972,RC,74160,HCPCS,Outpatient,,,327,196.2,,277.95,85,,222.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.7,80.03,,209.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,294.3,90,,235.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,287.76,88,,230.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.27,33.11,,86.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.13,294.3,
Ultrasound of abdomen with all areas scanned,8976700,CDM,972,RC,76700,HCPCS,Outpatient,,,327,196.2,,277.95,85,,222.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,261.7,80.03,,209.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,294.3,90,,235.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,105.13,32.15,,84.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,287.76,88,,230.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,108.27,33.11,,86.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,105.13,294.3,
MRI HEAD WO DYE,8970540,CDM,972,RC,70540,HCPCS,Outpatient,,,332,199.2,,282.2,85,,225.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.74,32.15,,85.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.7,80.03,,212.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,298.8,90,,239.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.74,32.15,,85.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,106.74,32.15,,85.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.16,88,,233.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.93,33.11,,87.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,106.74,298.8,
MRI of upper extremity without dye,8973221,CDM,972,RC,73221,HCPCS,Outpatient,,,332,199.2,,282.2,85,,225.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,106.74,32.15,,85.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,265.7,80.03,,212.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,298.8,90,,239.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,106.74,32.15,,85.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,106.74,32.15,,85.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.16,88,,233.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,109.93,33.11,,87.94,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,106.74,298.8,
MRI BRAIN W/  CONTRAST,8970552,CDM,972,RC,70552,HCPCS,Outpatient,,,333,199.8,,283.05,85,,226.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.06,32.15,,85.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,266.5,80.03,,213.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,299.7,90,,239.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.06,32.15,,85.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,107.06,32.15,,85.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.04,88,,234.43,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,110.26,33.11,,88.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.06,299.7,
INSERT ARTERIAL CATH CUTDOWN,1936625,CDM,981,RC,36625,HCPCS,Outpatient,,,333.25,199.95,,283.26,85,,226.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.14,32.15,,85.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,266.7,80.03,,213.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.93,90,,239.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.14,32.15,,85.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,333.25,,,,Other,Not Separately reimbursable,107.14,32.15,,85.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,293.26,88,,234.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,110.34,33.11,,88.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.14,299.93,
CONTROL POST / NASAL HEMORRHAGE,1930905,CDM,981,RC,30905,HCPCS,Outpatient,,,335.25,201.15,,284.96,85,,227.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,107.78,32.15,,86.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.3,80.03,,214.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.3,102,,,fee schedule,Pays at 102% of CMS APC rate,301.73,90,,241.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,107.78,32.15,,86.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.3,100,,,fee schedule,Pays at 100% of CMS APC rate,107.78,32.15,,86.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.02,88,,236.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111,33.11,,88.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,107.78,301.73,
MRI scan of lower spinal canal,8972148,CDM,972,RC,72148,HCPCS,Outpatient,,,336,201.6,,285.6,85,,228.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.02,32.15,,86.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.9,80.03,,215.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,302.4,90,,241.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.02,32.15,,86.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,108.02,32.15,,86.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.68,88,,236.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.25,33.11,,89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.02,302.4,
MRI LUMBAR W/ DYE,8972149,CDM,972,RC,72149,HCPCS,Outpatient,,,336,201.6,,285.6,85,,228.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.02,32.15,,86.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.9,80.03,,215.12,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,302.4,90,,241.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.02,32.15,,86.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,108.02,32.15,,86.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.68,88,,236.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.25,33.11,,89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.02,302.4,
I&D OF VULVA OR PERINEAL ABSCESS,1956405,CDM,981,RC,56405,HCPCS,Outpatient,,,336.5,201.9,,286.03,85,,228.82,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.18,32.15,,86.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,269.3,80.03,,215.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,279.89,102,,,fee schedule,Pays at 102% of CMS APC rate,302.85,90,,242.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.18,32.15,,86.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.89,100,,,fee schedule,Pays at 100% of CMS APC rate,108.18,32.15,,86.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,296.12,88,,236.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.42,33.11,,89.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.18,302.85,
MRI of chest and spine without dye,8972146,CDM,972,RC,72146,HCPCS,Outpatient,,,337,202.2,,286.45,85,,229.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.35,32.15,,86.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,269.7,80.03,,215.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,303.3,90,,242.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.35,32.15,,86.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,108.35,32.15,,86.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,296.56,88,,237.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,111.58,33.11,,89.26,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.35,303.3,
US ABDOMINAL AORTA,8976706,CDM,972,RC,76706,HCPCS,Outpatient,,,338.5,203.1,,287.73,85,,230.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,108.83,32.15,,87.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,270.9,80.03,,216.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,304.65,90,,243.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,108.83,32.15,,87.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,108.83,32.15,,87.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,297.88,88,,238.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.08,33.11,,89.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,108.83,304.65,
"OBS/INPT SAME DAY ADMIT / D/C, LOW",8799234,CDM,960,RC,99233,HCPCS,Outpatient,,,339.9,203.94,,288.92,85,,231.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,109.28,32.15,,87.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,272.02,80.03,,217.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,305.91,90,,244.73,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,109.28,32.15,,87.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,339.9,,,,Other,Not Separately reimbursable,109.28,32.15,,87.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,299.11,88,,239.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,112.54,33.11,,90.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,109.28,305.91,
PERICARDIOCENTESIS,1933010,CDM,981,RC,33016,HCPCS,Outpatient,,,342.5,205.5,,291.13,85,,232.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.11,32.15,,88.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.1,80.03,,219.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,308.25,90,,246.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.11,32.15,,88.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,110.11,32.15,,88.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.4,88,,241.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.4,33.11,,90.72,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.11,308.25,
CT ORBIT/EAR/FOSSA W/DYE,8970481,CDM,972,RC,70481,HCPCS,Outpatient,,,343,205.8,,291.55,85,,233.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.5,80.03,,219.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,308.7,90,,246.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.84,88,,241.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.57,33.11,,90.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.27,308.7,
CT scan of neck with dye,8970491,CDM,972,RC,70491,HCPCS,Outpatient,,,343,205.8,,291.55,85,,233.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.5,80.03,,219.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,308.7,90,,246.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.84,88,,241.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.57,33.11,,90.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.27,308.7,
CT THORAX  WWO DYE,8971270,CDM,972,RC,71270,HCPCS,Outpatient,,,343,205.8,,291.55,85,,233.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,274.5,80.03,,219.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,308.7,90,,246.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,110.27,32.15,,88.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.84,88,,241.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,113.57,33.11,,90.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.27,308.7,
"INT LAC>30.0 CM BODY, SC",1912037,CDM,981,RC,12037,HCPCS,Outpatient,,,344.75,206.85,,293.04,85,,234.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.84,32.15,,88.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,275.9,80.03,,220.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,310.28,90,,248.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.84,32.15,,88.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,110.84,32.15,,88.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,303.38,88,,242.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.15,33.11,,91.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.84,310.28,
CARDIOVERSION,1992960,CDM,981,RC,92960,HCPCS,Outpatient,,,344.75,206.85,,293.04,85,,234.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,110.84,32.15,,88.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,275.9,80.03,,220.72,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,563.84,102,,,fee schedule,Pays at 102% of CMS APC rate,310.28,90,,248.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,110.84,32.15,,88.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,563.84,100,,,fee schedule,Pays at 100% of CMS APC rate,110.84,32.15,,88.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,303.38,88,,242.7,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.15,33.11,,91.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,110.84,310.28,
"INITIAL OBS HOSPITAL CARE,MOD",8799219,CDM,960,RC,99219,HCPCS,Outpatient,,,345.3,207.18,,293.51,85,,234.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111.01,32.15,,88.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,276.34,80.03,,221.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.77,90,,248.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111.01,32.15,,88.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,345.3,,,,Other,Not Separately reimbursable,111.01,32.15,,88.81,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,303.86,88,,243.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.33,33.11,,91.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,111.01,310.77,
PARACENTESIS INIT PERITON LAVAGE,1949080,CDM,981,RC,49084,HCPCS,Outpatient,,,346.75,208.05,,294.74,85,,235.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,111.48,32.15,,89.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,277.5,80.03,,222,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,791.41,102,,,fee schedule,Pays at 102% of CMS APC rate,312.08,90,,249.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,111.48,32.15,,89.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,791.41,100,,,fee schedule,Pays at 100% of CMS APC rate,111.48,32.15,,89.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,305.14,88,,244.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,114.81,33.11,,91.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,111.48,312.08,
CLSD TX METATARSOPHAL JT DISLOC,1928630,CDM,981,RC,28630,HCPCS,Outpatient,,,348.75,209.25,,296.44,85,,237.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.1,80.03,,223.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,313.88,90,,251.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,306.9,88,,245.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.47,33.11,,92.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.12,313.88,
CRITICAL CARE EACH ADD'L 1/2 HOUR,1999292,CDM,981,RC,99292,HCPCS,Outpatient,,,348.75,209.25,,296.44,85,,237.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.1,80.03,,223.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.88,90,,251.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,348.75,,,,Other,Not Separately reimbursable,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,306.9,88,,245.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.47,33.11,,92.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.12,313.88,
CRITICAL CARE ADD'L 1/2 HR W/ PROC,1999301,CDM,981,RC,99292,HCPCS,Outpatient,,,348.75,209.25,,296.44,85,,237.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.1,80.03,,223.28,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.88,90,,251.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,348.75,,,,Other,Not Separately reimbursable,112.12,32.15,,89.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,306.9,88,,245.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.47,33.11,,92.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.12,313.88,
DRESS OR DEBRIDE BURN MEDIUM 1-2 DEGREE,1916025,CDM,981,RC,16025,HCPCS,Outpatient,,,349.75,209.85,,297.29,85,,237.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.9,80.03,,223.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,314.78,90,,251.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.78,88,,246.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.8,33.11,,92.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.44,314.78,
ENUC / EXC THROMBOSED HEMORRHOID,1946320,CDM,981,RC,46320,HCPCS,Outpatient,,,349.75,209.85,,297.29,85,,237.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,279.9,80.03,,223.92,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1038.18,102,,,fee schedule,Pays at 102% of CMS APC rate,314.78,90,,251.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1038.18,100,,,fee schedule,Pays at 100% of CMS APC rate,112.44,32.15,,89.95,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.78,88,,246.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.8,33.11,,92.64,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.44,314.78,
MRI of abdomen without dye,8974181,CDM,972,RC,74181,HCPCS,Outpatient,,,350,210,,297.5,85,,238,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.11,80.03,,224.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,315,90,,252,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308,88,,246.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.89,33.11,,92.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.53,315,
MRI ABDOMEN W/  CONTRAST,8974182,CDM,972,RC,74182,HCPCS,Outpatient,,,350,210,,297.5,85,,238,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.11,80.03,,224.09,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,315,90,,252,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,112.53,32.15,,90.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308,88,,246.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,115.89,33.11,,92.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.53,315,
"INITIAL INPT HOSPITAL CARE , MOD",8799222,CDM,987,RC,99222,HCPCS,Outpatient,,,350.7,210.42,,298.1,85,,238.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,112.75,32.15,,90.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,280.67,80.03,,224.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.63,90,,252.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,112.75,32.15,,90.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.7,,,,Other,Not Separately reimbursable,112.75,32.15,,90.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308.62,88,,246.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.12,33.11,,92.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,112.75,315.63,
REMOVAL OF NAIL BED-PERMANENT,1911750,CDM,981,RC,11750,HCPCS,Outpatient,,,353,211.8,,300.05,85,,240.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,282.51,80.03,,226.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,317.7,90,,254.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,113.49,32.15,,90.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,310.64,88,,248.51,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,116.88,33.11,,93.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,113.49,317.7,
"Emergency department visit, problem of high severity",1499284,CDM,981,RC,99284,HCPCS,Outpatient,,,356,213.6,,302.6,85,,242.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,284.91,80.03,,227.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,365.84,102,,,fee schedule,Pays at 102% of CMS APC rate,320.4,90,,256.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.84,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,313.28,88,,250.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,284.91,385,
"REPAIR OF NAIL BED, SIMPLE",1911760,CDM,981,RC,11760,HCPCS,Outpatient,,,357,214.2,,303.45,85,,242.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.78,32.15,,91.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,285.71,80.03,,228.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,321.3,90,,257.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.78,32.15,,91.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,114.78,32.15,,91.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.16,88,,251.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.2,33.11,,94.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.78,321.3,
REMOVE EMBED FB - EYELID,1967938,CDM,981,RC,67938,HCPCS,Outpatient,,,357,214.2,,303.45,85,,242.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,114.78,32.15,,91.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,285.71,80.03,,228.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,253.77,102,,,fee schedule,Pays at 102% of CMS APC rate,321.3,90,,257.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,114.78,32.15,,91.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.77,100,,,fee schedule,Pays at 100% of CMS APC rate,114.78,32.15,,91.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,314.16,88,,251.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.2,33.11,,94.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,114.78,321.3,
CT ORBIT/EAR/FOSSA W/ & W/O DYE,8970482,CDM,972,RC,70482,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.53,33.11,,94.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.1,322.2,
CT MAXILLOFACIAL BONES W AND WO CONTRAST,8970488,CDM,972,RC,70488,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.53,33.11,,94.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.1,322.2,
CT SOFT TISSUE NECK W/ & W/O DYE,8970492,CDM,972,RC,70492,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.53,33.11,,94.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.1,322.2,
I&D ABSCESS EYELID,1967700,CDM,981,RC,67700,HCPCS,Outpatient,,,358,214.8,,304.3,85,,243.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,286.51,80.03,,229.21,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,253.77,102,,,fee schedule,Pays at 102% of CMS APC rate,322.2,90,,257.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,253.77,100,,,fee schedule,Pays at 100% of CMS APC rate,115.1,32.15,,92.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.04,88,,252.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,118.53,33.11,,94.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.1,322.2,
MRI JAW JOINT,8970336,CDM,972,RC,70336,HCPCS,Outpatient,,,360,216,,306,85,,244.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,288.11,80.03,,230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,324,90,,259.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,316.8,88,,253.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.2,33.11,,95.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.74,324,
MRI HEAD W DYE,8970542,CDM,972,RC,70542,HCPCS,Outpatient,,,360,216,,306,85,,244.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,288.11,80.03,,230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,324,90,,259.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,316.8,88,,253.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.2,33.11,,95.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.74,324,
MRI THORACIC  SPINE W DYE,8972147,CDM,972,RC,72147,HCPCS,Outpatient,,,360,216,,306,85,,244.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,288.11,80.03,,230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,324,90,,259.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,316.8,88,,253.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.2,33.11,,95.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.74,324,
MRI of pelvis without dye,8972195,CDM,972,RC,72195,HCPCS,Outpatient,,,360,216,,306,85,,244.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,288.11,80.03,,230.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,324,90,,259.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,115.74,32.15,,92.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,316.8,88,,253.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.2,33.11,,95.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,115.74,324,
MRI of the neck or spine without dye,8972141,CDM,972,RC,72141,HCPCS,Outpatient,,,362,217.2,,307.7,85,,246.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,116.38,32.15,,93.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,289.71,80.03,,231.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,325.8,90,,260.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,116.38,32.15,,93.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,116.38,32.15,,93.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.56,88,,254.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.86,33.11,,95.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,116.38,325.8,
MRI C-SPINE W/  CONTRAST,8972142,CDM,972,RC,72142,HCPCS,Outpatient,,,362,217.2,,307.7,85,,246.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,116.38,32.15,,93.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,289.71,80.03,,231.77,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,325.8,90,,260.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,116.38,32.15,,93.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,116.38,32.15,,93.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.56,88,,254.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,119.86,33.11,,95.89,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,116.38,325.8,
MRI UPPER EXTREMITY W DYE,8927221,CDM,972,RC,73222,HCPCS,Outpatient,,,364,218.4,,309.4,85,,247.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.03,32.15,,93.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,291.31,80.03,,233.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,327.6,90,,262.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.03,32.15,,93.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,117.03,32.15,,93.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,320.32,88,,256.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,120.52,33.11,,96.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.03,327.6,
MRI UPPER EXTREMITY JOINT W DYE,8973222,CDM,972,RC,73222,HCPCS,Outpatient,,,364,218.4,,309.4,85,,247.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.03,32.15,,93.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,291.31,80.03,,233.05,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,710.15,102,,,fee schedule,Pays at 102% of CMS APC rate,327.6,90,,262.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.03,32.15,,93.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,710.15,100,,,fee schedule,Pays at 100% of CMS APC rate,117.03,32.15,,93.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,320.32,88,,256.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,120.52,33.11,,96.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.03,327.6,
CVC PERVCUTANEOUS,1936569,CDM,981,RC,36569,HCPCS,Outpatient,,,365.55,219.33,,310.72,85,,248.58,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,117.52,32.15,,94.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,292.55,80.03,,234.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,329,90,,263.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,117.52,32.15,,94.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,117.52,32.15,,94.02,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.68,88,,257.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.03,33.11,,96.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,117.52,329,
"Incision and drainage of hematoma, seroma or fluid collection",1910140,CDM,981,RC,10140,HCPCS,Outpatient,,,367.5,220.5,,312.38,85,,249.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.15,32.15,,94.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,294.11,80.03,,235.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,330.75,90,,264.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.15,32.15,,94.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,118.15,32.15,,94.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,323.4,88,,258.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.68,33.11,,97.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.15,330.75,
"Emergency department visit, problem of high severity",1999284,CDM,981,RC,99284,HCPCS,Outpatient,,,367.5,220.5,,312.38,85,,249.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,294.11,80.03,,235.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,365.84,102,,,fee schedule,Pays at 102% of CMS APC rate,330.75,90,,264.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.84,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,323.4,88,,258.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.11,385,
"Emergency department visit, problem of high severity",1999298,CDM,981,RC,99284,HCPCS,Outpatient,,,367.5,220.5,,312.38,85,,249.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,294.11,80.03,,235.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,365.84,102,,,fee schedule,Pays at 102% of CMS APC rate,330.75,90,,264.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.84,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,323.4,88,,258.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.11,385,
MRI of brain stem without dye,8970551,CDM,972,RC,70551,HCPCS,Outpatient,,,368,220.8,,312.8,85,,250.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.31,32.15,,94.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,294.51,80.03,,235.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,331.2,90,,264.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.31,32.15,,94.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,118.31,32.15,,94.65,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,323.84,88,,259.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,121.84,33.11,,97.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.31,331.2,
I&D EXT EAR,1969000,CDM,981,RC,69000,HCPCS,Outpatient,,,369.5,221.7,,314.08,85,,251.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,118.79,32.15,,95.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,295.71,80.03,,236.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,332.55,90,,266.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,118.79,32.15,,95.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,118.79,32.15,,95.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.16,88,,260.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,122.34,33.11,,97.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,118.79,332.55,
SIM LAC 20.1-30.0 CM,1912006,CDM,981,RC,12006,HCPCS,Outpatient,,,371.5,222.9,,315.78,85,,252.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,119.44,32.15,,95.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,297.31,80.03,,237.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,334.35,90,,267.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,119.44,32.15,,95.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,119.44,32.15,,95.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.92,88,,261.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,123,33.11,,98.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,119.44,334.35,
CLSD TX TOE FX W/O MANIP,1928510,CDM,981,RC,28510,HCPCS,Outpatient,,,371.5,222.9,,315.78,85,,252.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,119.44,32.15,,95.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,297.31,80.03,,237.85,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,334.35,90,,267.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,119.44,32.15,,95.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,119.44,32.15,,95.55,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.92,88,,261.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,123,33.11,,98.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,119.44,334.35,
ENDOTRACH INTUBATION PROFEE,8731500,CDM,960,RC,31500,HCPCS,Outpatient,,,373.25,223.95,,317.26,85,,253.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,120,32.15,,96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,298.71,80.03,,238.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,335.93,90,,268.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,120,32.15,,96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,120,32.15,,96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,328.46,88,,262.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,123.58,33.11,,98.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120,335.93,
ENDOTRACH INTUBATION,1931500,CDM,981,RC,31500,HCPCS,Outpatient,,,373.25,223.95,,317.26,85,,253.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,120,32.15,,96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,298.71,80.03,,238.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,335.93,90,,268.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,120,32.15,,96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,120,32.15,,96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,328.46,88,,262.77,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,123.58,33.11,,98.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120,335.93,
"CHANGE CYSTOSTOMY TUBE, SIMPLE",1451705,CDM,981,RC,51705,HCPCS,Outpatient,,,375.25,225.15,,318.96,85,,255.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,120.64,32.15,,96.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,300.31,80.03,,240.25,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,205.98,102,,,fee schedule,Pays at 102% of CMS APC rate,337.73,90,,270.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,120.64,32.15,,96.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,205.98,100,,,fee schedule,Pays at 100% of CMS APC rate,120.64,32.15,,96.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,330.22,88,,264.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,124.25,33.11,,99.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,120.64,337.73,
CONTRAST XRAY GALLBLADDER,8974290,CDM,972,RC,74290,HCPCS,Outpatient,,,377,226.2,,320.45,85,,256.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,121.21,32.15,,96.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,301.71,80.03,,241.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,339.3,90,,271.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,121.21,32.15,,96.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,121.21,32.15,,96.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.76,88,,265.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,124.82,33.11,,99.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,121.21,339.3,
CT SOFT TISSUE NECK W/O DYE,8970490,CDM,972,RC,70490,HCPCS,Outpatient,,,382,229.2,,324.7,85,,259.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,122.81,32.15,,98.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,305.71,80.03,,244.57,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,343.8,90,,275.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,122.81,32.15,,98.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,122.81,32.15,,98.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,336.16,88,,268.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,126.48,33.11,,101.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,122.81,343.8,
CENTRAL VENOUS CATH PERCUTANEOUS >2 Y/O,1936489,CDM,981,RC,36556,HCPCS,Outpatient,,,384,230.4,,326.4,85,,261.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.32,80.03,,245.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,345.6,90,,276.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.92,88,,270.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,127.14,33.11,,101.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,123.46,345.6,
CENTRAL LINE,1999302,CDM,981,RC,36556,HCPCS,Outpatient,,,384,230.4,,326.4,85,,261.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,307.32,80.03,,245.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2855.95,102,,,fee schedule,Pays at 102% of CMS APC rate,345.6,90,,276.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2855.95,100,,,fee schedule,Pays at 100% of CMS APC rate,123.46,32.15,,98.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.92,88,,270.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,127.14,33.11,,101.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,123.46,345.6,
CLSD TX BIG TOE FX W/O MANIP,1928490,CDM,981,RC,28490,HCPCS,Outpatient,,,386,231.6,,328.1,85,,262.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308.92,80.03,,247.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,347.4,90,,277.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,339.68,88,,271.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,127.8,33.11,,102.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,124.1,347.4,
REM PHARYNGEAL FOREIGN BODY,1942809,CDM,981,RC,42809,HCPCS,Outpatient,,,386,231.6,,328.1,85,,262.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,308.92,80.03,,247.14,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,347.4,90,,277.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,124.1,32.15,,99.28,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,339.68,88,,271.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,127.8,33.11,,102.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,124.1,347.4,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,8971275,CDM,972,RC,71275,HCPCS,Outpatient,,,389,233.4,,330.65,85,,264.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,125.06,32.15,,100.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,311.32,80.03,,249.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,350.1,90,,280.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,125.06,32.15,,100.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,125.06,32.15,,100.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,342.32,88,,273.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,128.8,33.11,,103.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,125.06,350.1,
CTA HEAD W/ & W/O CONTRAST,8970496,CDM,972,RC,70496,HCPCS,Outpatient,,,394,236.4,,334.9,85,,267.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,126.67,32.15,,101.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.32,80.03,,252.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,354.6,90,,283.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,126.67,32.15,,101.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,126.67,32.15,,101.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,346.72,88,,277.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.45,33.11,,104.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,126.67,354.6,
CTA OF NECK,8970498,CDM,972,RC,70498,HCPCS,Outpatient,,,394,236.4,,334.9,85,,267.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,126.67,32.15,,101.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,315.32,80.03,,252.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,354.6,90,,283.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,126.67,32.15,,101.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,126.67,32.15,,101.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,346.72,88,,277.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,130.45,33.11,,104.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,126.67,354.6,
MRI UPPER JOINT W & WO DYE,8973223,CDM,972,RC,73223,HCPCS,Outpatient,,,398,238.8,,338.3,85,,270.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,127.96,32.15,,102.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,318.52,80.03,,254.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,358.2,90,,286.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,127.96,32.15,,102.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,127.96,32.15,,102.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.24,88,,280.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,131.78,33.11,,105.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,127.96,358.2,
"DIRECTION OF EMS, ACLS",1490520,CDM,981,RC,99288,HCPCS,Outpatient,,,398.75,239.25,,338.94,85,,271.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,128.2,32.15,,102.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,319.12,80.03,,255.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.88,90,,287.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,128.2,32.15,,102.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,128.2,32.15,,102.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,350.9,88,,280.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,132.03,33.11,,105.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,128.2,358.88,
MRI UPPER EXTREMITY WO DYE,8973218,CDM,972,RC,73218,HCPCS,Outpatient,,,400,240,,340,85,,272,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,128.6,32.15,,102.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,320.12,80.03,,256.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,360,90,,288,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,128.6,32.15,,102.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,128.6,32.15,,102.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352,88,,281.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,132.44,33.11,,105.95,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,128.6,360,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",1910160,CDM,981,RC,10160,HCPCS,Outpatient,,,401.5,240.9,,341.28,85,,273.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,129.08,32.15,,103.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,321.32,80.03,,257.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,361.35,90,,289.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,129.08,32.15,,103.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,129.08,32.15,,103.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.32,88,,282.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,132.94,33.11,,106.35,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,129.08,361.35,
MRA  ABDOMEN W/ OR  W/O CONTRAST,8974185,CDM,972,RC,74185,HCPCS,Outpatient,,,406,243.6,,345.1,85,,276.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.53,32.15,,104.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,324.92,80.03,,259.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.4,90,,292.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.53,32.15,,104.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,130.53,32.15,,104.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.28,88,,285.82,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.43,33.11,,107.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.53,365.4,
SIM LAC 12.6-20.0 CM,1912016,CDM,981,RC,12016,HCPCS,Outpatient,,,406.75,244.05,,345.74,85,,276.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,130.77,32.15,,104.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,325.52,80.03,,260.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,366.08,90,,292.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,130.77,32.15,,104.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,130.77,32.15,,104.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.94,88,,286.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,134.67,33.11,,107.74,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,130.77,366.08,
CTA PELVIS W/ W/O CONTRAST,8972191,CDM,972,RC,72191,HCPCS,Outpatient,,,408,244.8,,346.8,85,,277.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,131.17,32.15,,104.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,326.52,80.03,,261.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,367.2,90,,293.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,131.17,32.15,,104.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,131.17,32.15,,104.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.04,88,,287.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,135.09,33.11,,108.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,131.17,367.2,
CMPLX LAC 1.1-2.5 CM TRUNK,1913100,CDM,981,RC,13100,HCPCS,Outpatient,,,414.75,248.85,,352.54,85,,282.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.34,32.15,,106.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,331.92,80.03,,265.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,373.28,90,,298.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.34,32.15,,106.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,133.34,32.15,,106.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,364.98,88,,291.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.32,33.11,,109.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.34,373.28,
MRA  CAROTIDS W/ & W/O CONTRAST,8970549,CDM,972,RC,70549,HCPCS,Outpatient,,,416,249.6,,353.6,85,,282.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.92,80.03,,266.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,374.4,90,,299.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.08,88,,292.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.74,33.11,,110.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.74,374.4,
"I&D, ABSCESS, CYST, VESTIBULE OF MOUTH",1940800,CDM,981,RC,40800,HCPCS,Outpatient,,,416,249.6,,353.6,85,,282.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,332.92,80.03,,266.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,374.4,90,,299.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,133.74,32.15,,106.99,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.08,88,,292.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,137.74,33.11,,110.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,133.74,374.4,
"CMPLX LAC FACE,H,F,EA ADD 5CM OR LESS",1913133,CDM,981,RC,13133,HCPCS,Outpatient,,,417,250.2,,354.45,85,,283.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.07,32.15,,107.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,333.73,80.03,,266.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375.3,90,,300.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.07,32.15,,107.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,417,,,,Other,Not Separately reimbursable,134.07,32.15,,107.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.96,88,,293.57,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.07,33.11,,110.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.07,375.3,
MRI of pelvis before and after dye,8972197,CDM,972,RC,72197,HCPCS,Outpatient,,,419,251.4,,356.15,85,,284.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.71,32.15,,107.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,335.33,80.03,,268.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,377.1,90,,301.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.71,32.15,,107.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,134.71,32.15,,107.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,368.72,88,,294.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.73,33.11,,110.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.71,377.1,
MRA  PELVIS W/ OR WO DYE,8972198,CDM,972,RC,72198,HCPCS,Outpatient,,,419,251.4,,356.15,85,,284.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,134.71,32.15,,107.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,335.33,80.03,,268.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.1,90,,301.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,134.71,32.15,,107.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,419,,,,Other,Not Separately reimbursable,134.71,32.15,,107.77,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,368.72,88,,294.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,138.73,33.11,,110.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,134.71,377.1,
"REMOVAL OF F.B. FOOT,SUB",1928190,CDM,981,RC,28190,HCPCS,Outpatient,,,420.25,252.15,,357.21,85,,285.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,336.33,80.03,,269.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,378.23,90,,302.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,135.11,32.15,,108.09,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,369.82,88,,295.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.14,33.11,,111.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.11,378.23,
DRESS OR DEBRIDE BURN LARGE 9%,1916030,CDM,981,RC,16030,HCPCS,Outpatient,,,421.25,252.75,,358.06,85,,286.45,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.43,32.15,,108.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.13,80.03,,269.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,379.13,90,,303.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.43,32.15,,108.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,135.43,32.15,,108.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,370.7,88,,296.56,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.48,33.11,,111.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.43,379.13,
CLSD TX NASAL FX W/STABILIZATION,1921320,CDM,981,RC,21320,HCPCS,Outpatient,,,422.25,253.35,,358.91,85,,287.13,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.75,32.15,,108.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,337.93,80.03,,270.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2727.54,102,,,fee schedule,Pays at 102% of CMS APC rate,380.03,90,,304.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.75,32.15,,108.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2727.54,100,,,fee schedule,Pays at 100% of CMS APC rate,135.75,32.15,,108.6,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,371.58,88,,297.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,139.81,33.11,,111.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.75,380.03,
MRA  LOWER EXTREMITY WITH OR W/O CONTRAS,8973725,CDM,972,RC,73725,HCPCS,Outpatient,,,423,253.8,,359.55,85,,287.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,135.99,32.15,,108.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,338.53,80.03,,270.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.7,90,,304.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,135.99,32.15,,108.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,423,,,,Other,Not Separately reimbursable,135.99,32.15,,108.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.24,88,,297.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,140.06,33.11,,112.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,135.99,380.7,
MRA  HEAD W &  W/O CONTRAST,8970546,CDM,972,RC,70546,HCPCS,Outpatient,,,424,254.4,,360.4,85,,288.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,136.32,32.15,,109.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,339.33,80.03,,271.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,381.6,90,,305.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,136.32,32.15,,109.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,136.32,32.15,,109.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.12,88,,298.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,140.39,33.11,,112.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,136.32,381.6,
I&D PERITONSILLAR ABSCESS,1942700,CDM,981,RC,42700,HCPCS,Outpatient,,,424.25,254.55,,360.61,85,,288.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,136.4,32.15,,109.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,339.53,80.03,,271.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,381.83,90,,305.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,136.4,32.15,,109.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,136.4,32.15,,109.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,373.34,88,,298.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,140.47,33.11,,112.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,136.4,381.83,
"I & D FINGER ABSCESS, SIMPLE",1926010,CDM,981,RC,26010,HCPCS,Outpatient,,,425.5,255.3,,361.68,85,,289.34,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,136.8,32.15,,109.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,340.53,80.03,,272.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,382.95,90,,306.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,136.8,32.15,,109.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,136.8,32.15,,109.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,374.44,88,,299.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,140.88,33.11,,112.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,136.8,382.95,
MM CTA ABDOMEN W/ W/O CONTRAST,8974175,CDM,972,RC,74175,HCPCS,Outpatient,,,427,256.2,,362.95,85,,290.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,137.28,32.15,,109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,341.73,80.03,,273.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,384.3,90,,307.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,137.28,32.15,,109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,137.28,32.15,,109.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,375.76,88,,300.61,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,141.38,33.11,,113.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,137.28,384.3,
CTA OF LOWER EXTREMITY W/&W/O CONTRAST,8973706,CDM,972,RC,73706,HCPCS,Outpatient,,,428,256.8,,363.8,85,,291.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,137.6,32.15,,110.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,342.53,80.03,,274.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,385.2,90,,308.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,137.6,32.15,,110.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,137.6,32.15,,110.08,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.64,88,,301.31,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,141.71,33.11,,113.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,137.6,385.2,
"TX SUPERFICIAL WOUND DEHISCIENCE,W/PACKI",1912021,CDM,981,RC,12021,HCPCS,Outpatient,,,429.5,257.7,,365.08,85,,292.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,138.08,32.15,,110.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,343.73,80.03,,274.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,386.55,90,,309.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,138.08,32.15,,110.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,138.08,32.15,,110.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,377.96,88,,302.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,142.21,33.11,,113.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,138.08,386.55,
"OBS/INPT SAME DAY ADMIT / D/C, MOD",8799235,CDM,960,RC,99235,HCPCS,Outpatient,,,430.05,258.03,,365.54,85,,292.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,138.26,32.15,,110.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,344.17,80.03,,275.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.05,90,,309.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,138.26,32.15,,110.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.05,,,,Other,Not Separately reimbursable,138.26,32.15,,110.61,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,378.44,88,,302.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,142.39,33.11,,113.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,138.26,387.05,
CONTROL POST/NASL HEM SUBSEQUENT,1930906,CDM,981,RC,30906,HCPCS,Outpatient,,,431.5,258.9,,366.78,85,,293.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,138.73,32.15,,110.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,345.33,80.03,,276.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,388.35,90,,310.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,138.73,32.15,,110.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,138.73,32.15,,110.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,379.72,88,,303.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,142.87,33.11,,114.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,138.73,388.35,
REPAIR CONJUNCT LACERATION,1965270,CDM,981,RC,65270,HCPCS,Outpatient,,,432.75,259.65,,367.84,85,,294.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,139.13,32.15,,111.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,346.33,80.03,,277.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2026.91,102,,,fee schedule,Pays at 102% of CMS APC rate,389.48,90,,311.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,139.13,32.15,,111.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2026.91,100,,,fee schedule,Pays at 100% of CMS APC rate,139.13,32.15,,111.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,380.82,88,,304.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,143.28,33.11,,114.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,139.13,389.48,
I&D EXT AUDITORY CANAL,1969020,CDM,981,RC,69020,HCPCS,Outpatient,,,440,264,,374,85,,299.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.13,80.03,,281.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,396,90,,316.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,141.46,32.15,,113.17,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.2,88,,309.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,145.68,33.11,,116.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.46,396,
MRI scan of brain before and after contrast,8970553,CDM,972,RC,70553,HCPCS,Outpatient,,,441,264.6,,374.85,85,,299.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.93,80.03,,282.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,396.9,90,,317.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.08,88,,310.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.02,33.11,,116.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.78,396.9,
MRI BREAST,8977021,CDM,972,RC,77021,HCPCS,Outpatient,,,441,264.6,,374.85,85,,299.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.93,80.03,,282.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.9,90,,317.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,441,,,,Other,Not Separately reimbursable,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.08,88,,310.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.02,33.11,,116.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.78,396.9,
MRI BREAST WITH OR W/O UNILATERIAL,8977058,CDM,972,RC,77058,HCPCS,Outpatient,,,441,264.6,,374.85,85,,299.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.93,80.03,,282.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.9,90,,317.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,441,,,,Other,Not Separately reimbursable,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.08,88,,310.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.02,33.11,,116.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.78,396.9,
MRI BREAST SCREENING,8977059,CDM,972,RC,77049,HCPCS,Outpatient,,,441,264.6,,374.85,85,,299.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,352.93,80.03,,282.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.9,90,,317.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,441,,,,Other,Not Separately reimbursable,141.78,32.15,,113.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.08,88,,310.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.02,33.11,,116.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.78,396.9,
CT UPPER  EXTREMITY  W/ WO,8973202,CDM,972,RC,73201,HCPCS,Outpatient,,,441.4,264.84,,375.19,85,,300.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,141.91,32.15,,113.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.25,80.03,,282.6,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,397.26,90,,317.81,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,141.91,32.15,,113.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,141.91,32.15,,113.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.43,88,,310.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.15,33.11,,116.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,141.91,397.26,
CT scan of the thorax without dye,8971250,CDM,972,RC,71250,HCPCS,Outpatient,,,442,265.2,,375.7,85,,300.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.73,80.03,,282.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,102.45,102,,,fee schedule,Pays at 102% of CMS APC rate,397.8,90,,318.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,102.45,100,,,fee schedule,Pays at 100% of CMS APC rate,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.96,88,,311.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.35,33.11,,117.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.1,397.8,
MRI of lower back with and without dye,8972158,CDM,972,RC,72158,HCPCS,Outpatient,,,442,265.2,,375.7,85,,300.56,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.73,80.03,,282.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,397.8,90,,318.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,142.1,32.15,,113.68,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.96,88,,311.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.35,33.11,,117.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.1,397.8,
CLSD TX STERNUM FX,1921820,CDM,981,RC,21820,HCPCS,Outpatient,,,443,265.8,,376.55,85,,301.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.42,32.15,,113.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,354.53,80.03,,283.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,398.7,90,,318.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.42,32.15,,113.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,142.42,32.15,,113.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,389.84,88,,311.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.68,33.11,,117.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.42,398.7,
CLSD TX TOE FX W/ MANIP,1928515,CDM,981,RC,28515,HCPCS,Outpatient,,,443,265.8,,376.55,85,,301.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,142.42,32.15,,113.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,354.53,80.03,,283.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,398.7,90,,318.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,142.42,32.15,,113.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,142.42,32.15,,113.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,389.84,88,,311.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,146.68,33.11,,117.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,142.42,398.7,
"CMPLX LAC N,E,E,L EA ADD 5CM OR LESS",1913153,CDM,981,RC,13153,HCPCS,Outpatient,,,449.25,269.55,,381.86,85,,305.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,144.43,32.15,,115.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,359.53,80.03,,287.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,404.33,90,,323.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,144.43,32.15,,115.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,449.25,,,,Other,Not Separately reimbursable,144.43,32.15,,115.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,395.34,88,,316.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,148.75,33.11,,119,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,144.43,404.33,
FB REM MUSCLE SIMPLE,1920520,CDM,981,RC,20520,HCPCS,Outpatient,,,456.5,273.9,,388.03,85,,310.42,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,365.34,80.03,,292.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,410.85,90,,328.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,146.76,32.15,,117.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,401.72,88,,321.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.15,33.11,,120.92,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,146.76,410.85,
CLSD TX PROXIMAL FIBULA FX W/O MAN,1927780,CDM,981,RC,27780,HCPCS,Outpatient,,,457.75,274.65,,389.09,85,,311.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.17,32.15,,117.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,366.34,80.03,,293.07,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,411.98,90,,329.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.17,32.15,,117.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,147.17,32.15,,117.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.82,88,,322.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,151.56,33.11,,121.25,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.17,411.98,
EXCISION BENIGN LESION,1911403,CDM,981,RC,11403,HCPCS,Outpatient,,,459.5,275.7,,390.58,85,,312.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,147.73,32.15,,118.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,367.74,80.03,,294.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,413.55,90,,330.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,147.73,32.15,,118.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,147.73,32.15,,118.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,404.36,88,,323.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,152.14,33.11,,121.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,147.73,413.55,
SIM LAC RPR>30CM BODY SCALP,1912007,CDM,981,RC,12007,HCPCS,Outpatient,,,464.75,278.85,,395.04,85,,316.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,371.94,80.03,,297.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.11,102,,,fee schedule,Pays at 102% of CMS APC rate,418.28,90,,334.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.11,100,,,fee schedule,Pays at 100% of CMS APC rate,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,408.98,88,,327.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,153.88,33.11,,123.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.42,418.28,
I&D ABSCESS DENTOALVEOLAR,1941800,CDM,981,RC,41800,HCPCS,Outpatient,,,464.75,278.85,,395.04,85,,316.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,371.94,80.03,,297.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,111.31,102,,,fee schedule,Pays at 102% of CMS APC rate,418.28,90,,334.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of CMS APC rate,149.42,32.15,,119.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,408.98,88,,327.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,153.88,33.11,,123.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.42,418.28,
CLSD TX BIG TOE FX W/ MANIP,1928495,CDM,981,RC,28495,HCPCS,Outpatient,,,465.75,279.45,,395.89,85,,316.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,372.74,80.03,,298.19,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,419.18,90,,335.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,149.74,32.15,,119.79,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,409.86,88,,327.89,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,154.21,33.11,,123.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,149.74,419.18,
I & D ABSCESS COMPLICATED OR MULTI PROFE,8710061,CDM,960,RC,10061,HCPCS,Outpatient,,,469.5,281.7,,399.08,85,,319.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.94,32.15,,120.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,375.74,80.03,,300.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,422.55,90,,338.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.94,32.15,,120.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,150.94,32.15,,120.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,413.16,88,,330.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.45,33.11,,124.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.94,422.55,
I & D ABSCESS COMPLICATED OR MULTIPLE,1910061,CDM,981,RC,10061,HCPCS,Outpatient,,,469.5,281.7,,399.08,85,,319.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,150.94,32.15,,120.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,375.74,80.03,,300.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,422.55,90,,338.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,150.94,32.15,,120.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,150.94,32.15,,120.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,413.16,88,,330.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.45,33.11,,124.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,150.94,422.55,
"INITIAL OBS HOSPITAL CARE, HIGH",8799220,CDM,960,RC,99220,HCPCS,Outpatient,,,470.63,282.38,,400.04,85,,320.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.31,32.15,,121.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.65,80.03,,301.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,423.57,90,,338.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.31,32.15,,121.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,470.63,,,,Other,Not Separately reimbursable,151.31,32.15,,121.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.15,88,,331.32,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.83,33.11,,124.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,151.31,423.57,
CT C-SPINE  W/ & W/O DYE,8972127,CDM,972,RC,72127,HCPCS,Outpatient,,,471,282.6,,400.35,85,,320.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.94,80.03,,301.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,423.9,90,,339.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.48,88,,331.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.95,33.11,,124.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,151.43,423.9,
CT SPINE  THORACIC WWO DYE,8972130,CDM,972,RC,72130,HCPCS,Outpatient,,,471,282.6,,400.35,85,,320.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.94,80.03,,301.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,423.9,90,,339.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.48,88,,331.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.95,33.11,,124.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,151.43,423.9,
CLSD TX NASAL FX W/O STABILIZATION,1921315,CDM,981,RC,21315,HCPCS,Outpatient,,,471,282.6,,400.35,85,,320.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,376.94,80.03,,301.55,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1330.81,102,,,fee schedule,Pays at 102% of CMS APC rate,423.9,90,,339.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.81,100,,,fee schedule,Pays at 100% of CMS APC rate,151.43,32.15,,121.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,414.48,88,,331.58,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,155.95,33.11,,124.76,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,151.43,423.9,
"INT LAC <2.5 CM NECK,HAND,FEET",1912041,CDM,981,RC,12041,HCPCS,Outpatient,,,473,283.8,,402.05,85,,321.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,152.07,32.15,,121.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,378.54,80.03,,302.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,425.7,90,,340.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,152.07,32.15,,121.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,152.07,32.15,,121.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,416.24,88,,332.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,156.61,33.11,,125.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,152.07,425.7,
CLSD TX TARSAL JT DISLOC,1928570,CDM,981,RC,28570,HCPCS,Outpatient,,,473,283.8,,402.05,85,,321.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,152.07,32.15,,121.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,378.54,80.03,,302.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,425.7,90,,340.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,152.07,32.15,,121.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,152.07,32.15,,121.66,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,416.24,88,,332.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,156.61,33.11,,125.29,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,152.07,425.7,
MRI NECK SOFT TISSUE WWO,8970543,CDM,972,RC,70543,HCPCS,Outpatient,,,479,287.4,,407.15,85,,325.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,383.34,80.03,,306.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,431.1,90,,344.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,421.52,88,,337.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.6,33.11,,126.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154,431.1,
MRI of neck/spine with and without dye,8972156,CDM,972,RC,72156,HCPCS,Outpatient,,,479,287.4,,407.15,85,,325.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,383.34,80.03,,306.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,431.1,90,,344.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,421.52,88,,337.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.6,33.11,,126.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154,431.1,
MRI of chest and spine with and without dye,8972157,CDM,972,RC,72157,HCPCS,Outpatient,,,479,287.4,,407.15,85,,325.72,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,383.34,80.03,,306.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,431.1,90,,344.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,154,32.15,,123.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,421.52,88,,337.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,158.6,33.11,,126.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154,431.1,
INT LAC <2.6 CM BODY SCALP,1912031,CDM,981,RC,12031,HCPCS,Outpatient,,,480.25,288.15,,408.21,85,,326.57,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,154.4,32.15,,123.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,384.34,80.03,,307.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,432.23,90,,345.78,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,154.4,32.15,,123.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,154.4,32.15,,123.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,422.62,88,,338.1,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,159.01,33.11,,127.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,154.4,432.23,
MOUTH LACERATION < 2.6 CM,1941250,CDM,981,RC,41250,HCPCS,Outpatient,,,484.5,290.7,,411.83,85,,329.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,387.75,80.03,,310.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,361.97,102,,,fee schedule,Pays at 102% of CMS APC rate,436.05,90,,348.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,361.97,100,,,fee schedule,Pays at 100% of CMS APC rate,155.77,32.15,,124.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,426.36,88,,341.09,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,160.42,33.11,,128.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,155.77,436.05,
"Emergency department visit, problem with significant threat to life or function",1499285,CDM,981,RC,99285,HCPCS,Outpatient,,,485.5,291.3,,412.68,85,,330.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,388.55,80.03,,310.84,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,525.47,102,,,fee schedule,Pays at 102% of CMS APC rate,436.95,90,,349.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,525.47,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,427.24,88,,341.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385,436.95,
DRAIN EXTERNAL ABSCESS / HEMATOMA COMP,1969005,CDM,981,RC,69005,HCPCS,Outpatient,,,488.5,293.1,,415.23,85,,332.18,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,390.95,80.03,,312.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,439.65,90,,351.72,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,157.05,32.15,,125.64,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,429.88,88,,343.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,161.74,33.11,,129.39,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,157.05,439.65,
"SIM LAC 20.1-30.0 CM FA,CH",1912017,CDM,981,RC,12017,HCPCS,Outpatient,,,494.75,296.85,,420.54,85,,336.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,395.95,80.03,,316.76,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,445.28,90,,356.22,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,159.06,32.15,,127.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,435.38,88,,348.3,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,163.81,33.11,,131.05,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,159.06,445.28,
CHEST TUBE,1932020,CDM,981,RC,32551,HCPCS,Outpatient,,,503,301.8,,427.55,85,,342.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,161.71,32.15,,129.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,402.55,80.03,,322.04,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1426.4,102,,,fee schedule,Pays at 102% of CMS APC rate,452.7,90,,362.16,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,161.71,32.15,,129.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1426.4,100,,,fee schedule,Pays at 100% of CMS APC rate,161.71,32.15,,129.37,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,442.64,88,,354.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,166.54,33.11,,133.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,161.71,452.7,
MRI UPPER EXTREMITY W & WO DYE,8973220,CDM,972,RC,73220,HCPCS,Outpatient,,,509,305.4,,432.65,85,,346.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,163.64,32.15,,130.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,407.35,80.03,,325.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,458.1,90,,366.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,163.64,32.15,,130.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,163.64,32.15,,130.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,447.92,88,,358.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,168.53,33.11,,134.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,163.64,458.1,
MRI of abdomen without and with dye,8974183,CDM,972,RC,74183,HCPCS,Outpatient,,,509,305.4,,432.65,85,,346.12,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,163.64,32.15,,130.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,407.35,80.03,,325.88,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,458.1,90,,366.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,163.64,32.15,,130.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,163.64,32.15,,130.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,447.92,88,,358.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,168.53,33.11,,134.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,163.64,458.1,
"INITIAL INPT HOSPITAL CARE , HIGH",8799223,CDM,987,RC,99223,HCPCS,Outpatient,,,514.8,308.88,,437.58,85,,350.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,165.51,32.15,,132.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,411.99,80.03,,329.59,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.32,90,,370.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,165.51,32.15,,132.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,514.8,,,,Other,Not Separately reimbursable,165.51,32.15,,132.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,453.02,88,,362.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,170.45,33.11,,136.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,165.51,463.32,
CLOSURE LACERATION VEST < 2.5 CM,1940830,CDM,981,RC,40830,HCPCS,Outpatient,,,524.75,314.85,,446.04,85,,356.83,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,168.71,32.15,,134.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,419.96,80.03,,335.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,472.28,90,,377.82,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,168.71,32.15,,134.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,168.71,32.15,,134.97,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,461.78,88,,369.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,173.74,33.11,,138.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,168.71,472.28,
I & D PILONIDAL CYST-COMPLICATED,1910081,CDM,981,RC,10081,HCPCS,Outpatient,,,530,318,,450.5,85,,360.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.16,80.03,,339.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,622.15,102,,,fee schedule,Pays at 102% of CMS APC rate,477,90,,381.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.15,100,,,fee schedule,Pays at 100% of CMS APC rate,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,466.4,88,,373.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,175.48,33.11,,140.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,170.4,477,
INSERTION OF TEMPORARY TRANS PACEMAKER,1933210,CDM,981,RC,33210,HCPCS,Outpatient,,,530,318,,450.5,85,,360.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,424.16,80.03,,339.33,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,7825.7,102,,,fee schedule,Pays at 102% of CMS APC rate,477,90,,381.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,7825.7,100,,,fee schedule,Pays at 100% of CMS APC rate,170.4,32.15,,136.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,466.4,88,,373.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,175.48,33.11,,140.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,170.4,477,
"INT LAC <2.6 CM FACE,EARS,EYES",1912051,CDM,981,RC,12051,HCPCS,Outpatient,,,538.25,322.95,,457.51,85,,366.01,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,173.05,32.15,,138.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,430.76,80.03,,344.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,484.43,90,,387.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,173.05,32.15,,138.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,173.05,32.15,,138.44,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,473.66,88,,378.93,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,178.21,33.11,,142.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,173.05,484.43,
CTA ABDOMINAL AORTA W/ W/O CONTRAST,8975635,CDM,972,RC,75635,HCPCS,Outpatient,,,541,324.6,,459.85,85,,367.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,173.93,32.15,,139.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,432.96,80.03,,346.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.89,102,,,fee schedule,Pays at 102% of CMS APC rate,486.9,90,,389.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,173.93,32.15,,139.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.89,100,,,fee schedule,Pays at 100% of CMS APC rate,173.93,32.15,,139.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,476.08,88,,380.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,179.13,33.11,,143.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,173.93,486.9,
CLSD TX TARSAL BONE DISL,1928540,CDM,981,RC,28540,HCPCS,Outpatient,,,541.25,324.75,,460.06,85,,368.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,174.01,32.15,,139.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,433.16,80.03,,346.53,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,487.13,90,,389.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,174.01,32.15,,139.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,174.01,32.15,,139.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,476.3,88,,381.04,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,179.21,33.11,,143.37,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,174.01,487.13,
"Emergency department visit, problem with significant threat to life or function",1999285,CDM,981,RC,99285,HCPCS,Outpatient,,,542.25,325.35,,460.91,85,,368.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,433.96,80.03,,347.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,525.47,102,,,fee schedule,Pays at 102% of CMS APC rate,488.03,90,,390.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,525.47,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.18,88,,381.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385,488.03,
"Emergency department visit, problem with significant threat to life or function",1999299,CDM,981,RC,99285,HCPCS,Outpatient,,,542.25,325.35,,460.91,85,,368.73,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,433.96,80.03,,347.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,525.47,102,,,fee schedule,Pays at 102% of CMS APC rate,488.03,90,,390.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,525.47,100,,,fee schedule,Pays at 100% of CMS APC rate,385,32.15,,308,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,477.18,88,,381.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,396.55,33.11,,317.24,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,385,488.03,
Image of the heart to assess perfusion,8978465,CDM,974,RC,78452,HCPCS,Outpatient,,,545,327,,463.25,85,,370.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,175.22,32.15,,140.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,436.16,80.03,,348.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1272.45,102,,,fee schedule,Pays at 102% of CMS APC rate,490.5,90,,392.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,175.22,32.15,,140.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1272.45,100,,,fee schedule,Pays at 100% of CMS APC rate,175.22,32.15,,140.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,479.6,88,,383.68,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,180.45,33.11,,144.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,175.22,490.5,
"OBS/INPT SAME DAY ADMIT / D/C, HIGH",8799236,CDM,960,RC,99236,HCPCS,Outpatient,,,553.58,332.15,,470.54,85,,376.43,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,177.98,32.15,,142.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,443.03,80.03,,354.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,498.22,90,,398.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,177.98,32.15,,142.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,553.58,,,,Other,Not Separately reimbursable,177.98,32.15,,142.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,487.15,88,,389.72,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,183.29,33.11,,146.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,177.98,498.22,
SIM LAC >30.0 CM,1912018,CDM,981,RC,12018,HCPCS,Outpatient,,,560,336,,476,85,,380.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,180.04,32.15,,144.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,448.17,80.03,,358.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,173.12,102,,,fee schedule,Pays at 102% of CMS APC rate,504,90,,403.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,180.04,32.15,,144.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,173.12,100,,,fee schedule,Pays at 100% of CMS APC rate,180.04,32.15,,144.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,492.8,88,,394.24,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,185.42,33.11,,148.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,180.04,504,
"CLSD TX FINGER FRACTURE W/O MANIP,EA",1926720,CDM,981,RC,26720,HCPCS,Outpatient,,,565,339,,480.25,85,,384.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,181.65,32.15,,145.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,452.17,80.03,,361.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,508.5,90,,406.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,181.65,32.15,,145.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,181.65,32.15,,145.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,497.2,88,,397.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,187.07,33.11,,149.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,181.65,508.5,
CLSD TX DISTAL TUFT FX W/O MANIP,1926750,CDM,981,RC,26750,HCPCS,Outpatient,,,565,339,,480.25,85,,384.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,181.65,32.15,,145.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,452.17,80.03,,361.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,508.5,90,,406.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,181.65,32.15,,145.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,181.65,32.15,,145.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,497.2,88,,397.76,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,187.07,33.11,,149.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,181.65,508.5,
CRITICAL CARE 1ST HOUR- PROFEE,8799291,CDM,960,RC,99291,HCPCS,Outpatient,,,566.23,339.74,,481.3,85,,385.04,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,182.04,32.15,,145.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,453.15,80.03,,362.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,736.01,102,,,fee schedule,Pays at 102% of CMS APC rate,509.61,90,,407.69,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,182.04,32.15,,145.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,736.01,100,,,fee schedule,Pays at 100% of CMS APC rate,182.04,32.15,,145.63,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,498.28,88,,398.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,187.48,33.11,,149.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,182.04,509.61,
"I & D FINGER ABSCESS, COM",1926011,CDM,981,RC,26011,HCPCS,Outpatient,,,574.5,344.7,,488.33,85,,390.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,184.7,32.15,,147.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,459.77,80.03,,367.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,517.05,90,,413.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,184.7,32.15,,147.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,184.7,32.15,,147.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,505.56,88,,404.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,190.22,33.11,,152.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,184.7,517.05,
CLSD TX HIP DISLOCATION  W/O ANEST,1927250,CDM,981,RC,27250,HCPCS,Outpatient,,,574.5,344.7,,488.33,85,,390.66,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,184.7,32.15,,147.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,459.77,80.03,,367.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,517.05,90,,413.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,184.7,32.15,,147.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,184.7,32.15,,147.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,505.56,88,,404.45,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,190.22,33.11,,152.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,184.7,517.05,
I & REM F. B. COMPLICATED,1910121,CDM,981,RC,10121,HCPCS,Outpatient,,,579.5,347.7,,492.58,85,,394.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,186.31,32.15,,149.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,463.77,80.03,,371.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,521.55,90,,417.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,186.31,32.15,,149.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,186.31,32.15,,149.05,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,509.96,88,,407.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,191.87,33.11,,153.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,186.31,521.55,
CRICOTHYROIDOTOMY,1931605,CDM,981,RC,31605,HCPCS,Outpatient,,,586.75,352.05,,498.74,85,,398.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,188.64,32.15,,150.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,469.58,80.03,,375.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,528.08,90,,422.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,188.64,32.15,,150.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,188.64,32.15,,150.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,516.34,88,,413.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,194.27,33.11,,155.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,188.64,528.08,
CLSD TX T-MT JOINT DISLOC,1928600,CDM,981,RC,28600,HCPCS,Outpatient,,,589,353.4,,500.65,85,,400.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,189.36,32.15,,151.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,471.38,80.03,,377.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,530.1,90,,424.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,189.36,32.15,,151.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,189.36,32.15,,151.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,518.32,88,,414.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,195.02,33.11,,156.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,189.36,530.1,
"TX SUPERFICIAL WOUND DEHISCIENCE, SIMPLE",1912020,CDM,981,RC,12020,HCPCS,Outpatient,,,590,354,,501.5,85,,401.2,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,189.69,32.15,,151.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,472.18,80.03,,377.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,531,90,,424.8,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,189.69,32.15,,151.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,189.69,32.15,,151.75,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,519.2,88,,415.36,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,195.35,33.11,,156.28,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,189.69,531,
CPR,1992950,CDM,981,RC,92950,HCPCS,Outpatient,,,591,354.6,,502.35,85,,401.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,190.01,32.15,,152.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,472.98,80.03,,378.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,268.48,102,,,fee schedule,Pays at 102% of CMS APC rate,531.9,90,,425.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,190.01,32.15,,152.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,268.48,100,,,fee schedule,Pays at 100% of CMS APC rate,190.01,32.15,,152.01,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,520.08,88,,416.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,195.68,33.11,,156.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,190.01,531.9,
"INT LAC RPR>30.0 CM FACE,EARS,EYES",1912057,CDM,981,RC,12057,HCPCS,Outpatient,,,594,356.4,,504.9,85,,403.92,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,475.38,80.03,,380.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,534.6,90,,427.68,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,190.97,32.15,,152.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,522.72,88,,418.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,196.67,33.11,,157.34,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,190.97,534.6,
"TX TARSAL BONE FX W/O MAN, EACH",1928450,CDM,981,RC,28450,HCPCS,Outpatient,,,595.25,357.15,,505.96,85,,404.77,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,191.37,32.15,,153.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,476.38,80.03,,381.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,535.73,90,,428.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,191.37,32.15,,153.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,191.37,32.15,,153.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,523.82,88,,419.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,197.09,33.11,,157.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,191.37,535.73,
CT of abdomen and pelvis without dye,8974176,CDM,972,RC,74176,HCPCS,Outpatient,,,610,366,,518.5,85,,414.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,196.12,32.15,,156.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,488.18,80.03,,390.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,549,90,,439.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,196.12,32.15,,156.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,196.12,32.15,,156.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,536.8,88,,429.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.97,33.11,,161.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,196.12,549,
"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",8974178,CDM,972,RC,74178,HCPCS,Outpatient,,,610,366,,518.5,85,,414.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,196.12,32.15,,156.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,488.18,80.03,,390.54,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,549,90,,439.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,196.12,32.15,,156.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,196.12,32.15,,156.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,536.8,88,,429.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,201.97,33.11,,161.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,196.12,549,
"INT LAC 2.6-7.5 CM BD,SC",1912032,CDM,981,RC,12032,HCPCS,Outpatient,,,611.75,367.05,,519.99,85,,415.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,196.68,32.15,,157.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,489.58,80.03,,391.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,550.58,90,,440.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,196.68,32.15,,157.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,196.68,32.15,,157.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,538.34,88,,430.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,202.55,33.11,,162.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,196.68,550.58,
INT LAC 2.6-7.5 CM,1912042,CDM,981,RC,12042,HCPCS,Outpatient,,,631.25,378.75,,536.56,85,,429.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,505.19,80.03,,404.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,568.13,90,,454.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,555.5,88,,444.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,209.01,33.11,,167.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,202.95,568.13,
"CLSD TX METATARSAL FX W/O MAN, EACH",1928470,CDM,981,RC,28470,HCPCS,Outpatient,,,631.25,378.75,,536.56,85,,429.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,505.19,80.03,,404.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,568.13,90,,454.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,202.95,32.15,,162.36,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,555.5,88,,444.4,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,209.01,33.11,,167.21,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,202.95,568.13,
INT LAC 2.6-5.0 CM,1912052,CDM,981,RC,12052,HCPCS,Outpatient,,,641.75,385.05,,545.49,85,,436.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,206.32,32.15,,165.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,513.59,80.03,,410.87,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,577.58,90,,462.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,206.32,32.15,,165.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,206.32,32.15,,165.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,564.74,88,,451.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,212.48,33.11,,169.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,206.32,577.58,
CLSD TX TALUS FX W/O MANIP,1928430,CDM,981,RC,28430,HCPCS,Outpatient,,,650,390,,552.5,85,,442,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,520.2,80.03,,416.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,585,90,,468,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,208.98,32.15,,167.18,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,572,88,,457.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,215.22,33.11,,172.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,208.98,585,
"INT LAC 7.6-12.5 CM BD,SC",1912034,CDM,981,RC,12034,HCPCS,Outpatient,,,652,391.2,,554.2,85,,443.36,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,209.62,32.15,,167.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,521.8,80.03,,417.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,586.8,90,,469.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,209.62,32.15,,167.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,209.62,32.15,,167.7,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,573.76,88,,459.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,215.88,33.11,,172.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,209.62,586.8,
CT scan of abdomen and pelvis with contrast,8974177,CDM,972,RC,74177,HCPCS,Outpatient,,,655,393,,556.75,85,,445.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,210.58,32.15,,168.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,524.2,80.03,,419.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,353.2,102,,,fee schedule,Pays at 102% of CMS APC rate,589.5,90,,471.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,210.58,32.15,,168.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,353.2,100,,,fee schedule,Pays at 100% of CMS APC rate,210.58,32.15,,168.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,576.4,88,,461.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,216.87,33.11,,173.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,210.58,589.5,
EXPLORATION OF PENETRATING WOUND CHEST,1920101,CDM,981,RC,20101,HCPCS,Outpatient,,,658.25,394.95,,559.51,85,,447.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,211.63,32.15,,169.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,526.8,80.03,,421.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,592.43,90,,473.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,211.63,32.15,,169.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,211.63,32.15,,169.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,579.26,88,,463.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,217.95,33.11,,174.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,211.63,592.43,
CLSD TX ARTICULAR FX W/O MAN,1926740,CDM,981,RC,26740,HCPCS,Outpatient,,,664.5,398.7,,564.83,85,,451.86,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,213.64,32.15,,170.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,531.8,80.03,,425.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,598.05,90,,478.44,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,213.64,32.15,,170.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,213.64,32.15,,170.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,584.76,88,,467.81,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,220.02,33.11,,176.02,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,213.64,598.05,
TONGUE LACERATION > 2.6 CM,1941252,CDM,981,RC,41252,HCPCS,Outpatient,,,670.75,402.45,,570.14,85,,456.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,215.65,32.15,,172.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,536.8,80.03,,429.44,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,199.23,102,,,fee schedule,Pays at 102% of CMS APC rate,603.68,90,,482.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,215.65,32.15,,172.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,199.23,100,,,fee schedule,Pays at 100% of CMS APC rate,215.65,32.15,,172.52,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,590.26,88,,472.21,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,222.09,33.11,,177.67,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,215.65,603.68,
INT LAC 7.6-12.5 CM,1912044,CDM,981,RC,12044,HCPCS,Outpatient,,,675.75,405.45,,574.39,85,,459.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,217.25,32.15,,173.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,540.8,80.03,,432.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,608.18,90,,486.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,217.25,32.15,,173.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,217.25,32.15,,173.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,594.66,88,,475.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,223.74,33.11,,178.99,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,217.25,608.18,
CLSD TX CLAVICLE FX W/O MANIP,1923500,CDM,981,RC,23500,HCPCS,Outpatient,,,682,409.2,,579.7,85,,463.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,219.26,32.15,,175.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,545.8,80.03,,436.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,613.8,90,,491.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,219.26,32.15,,175.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,219.26,32.15,,175.41,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,600.16,88,,480.13,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,225.81,33.11,,180.65,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,219.26,613.8,
INT LAC 5.1-7.5 CM,1912053,CDM,981,RC,12053,HCPCS,Outpatient,,,685.25,411.15,,582.46,85,,465.97,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,220.31,32.15,,176.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,548.41,80.03,,438.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,616.73,90,,493.38,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,220.31,32.15,,176.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,220.31,32.15,,176.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,603.02,88,,482.42,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,226.89,33.11,,181.51,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,220.31,616.73,
CRITICAL CARE 1ST HOUR,1999291,CDM,981,RC,99291,HCPCS,Outpatient,,,696.5,417.9,,592.03,85,,473.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,223.92,32.15,,179.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,557.41,80.03,,445.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,736.01,102,,,fee schedule,Pays at 102% of CMS APC rate,626.85,90,,501.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,223.92,32.15,,179.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,736.01,100,,,fee schedule,Pays at 100% of CMS APC rate,223.92,32.15,,179.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,612.92,88,,490.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,230.61,33.11,,184.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,223.92,626.85,
CRITICAL CARE 1ST HOUR W/ PROCEDURE,1999300,CDM,981,RC,99291,HCPCS,Outpatient,,,696.5,417.9,,592.03,85,,473.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,223.92,32.15,,179.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,557.41,80.03,,445.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,736.01,102,,,fee schedule,Pays at 102% of CMS APC rate,626.85,90,,501.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,223.92,32.15,,179.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,736.01,100,,,fee schedule,Pays at 100% of CMS APC rate,223.92,32.15,,179.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,612.92,88,,490.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,230.61,33.11,,184.49,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,223.92,626.85,
INT LAC 7.6-12.5 CM,1912054,CDM,981,RC,12054,HCPCS,Outpatient,,,700.75,420.45,,595.64,85,,476.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,225.29,32.15,,180.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,560.81,80.03,,448.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,630.68,90,,504.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,225.29,32.15,,180.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,225.29,32.15,,180.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,616.66,88,,493.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,232.02,33.11,,185.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,225.29,630.68,
CLSD TX AC JOINT DISLOCATION W/O MAN,1923540,CDM,981,RC,23540,HCPCS,Outpatient,,,700.75,420.45,,595.64,85,,476.51,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,225.29,32.15,,180.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,560.81,80.03,,448.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,630.68,90,,504.54,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,225.29,32.15,,180.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,225.29,32.15,,180.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,616.66,88,,493.33,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,232.02,33.11,,185.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,225.29,630.68,
CLSD TX CALCANEAL FX W/O MAN,1928400,CDM,981,RC,28400,HCPCS,Outpatient,,,701.75,421.05,,596.49,85,,477.19,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,225.61,32.15,,180.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,561.61,80.03,,449.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,631.58,90,,505.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,225.61,32.15,,180.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,225.61,32.15,,180.49,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,617.54,88,,494.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,232.35,33.11,,185.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,225.61,631.58,
"CLSD TX METATARSAL FX W/ MAN, EACH",1928475,CDM,981,RC,28475,HCPCS,Outpatient,,,707,424.2,,600.95,85,,480.76,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,227.3,32.15,,181.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,565.81,80.03,,452.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,636.3,90,,509.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,227.3,32.15,,181.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,227.3,32.15,,181.84,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.16,88,,497.73,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,234.09,33.11,,187.27,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,227.3,636.3,
CLOSURE LACERATION VEST > 2.5 CM,1940831,CDM,981,RC,40831,HCPCS,Outpatient,,,713,427.8,,606.05,85,,484.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,229.23,32.15,,183.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,570.61,80.03,,456.49,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,437.94,102,,,fee schedule,Pays at 102% of CMS APC rate,641.7,90,,513.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,229.23,32.15,,183.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.94,100,,,fee schedule,Pays at 100% of CMS APC rate,229.23,32.15,,183.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,627.44,88,,501.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,236.07,33.11,,188.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,229.23,641.7,
CLSD TX CLAVICLE DISLOC W/O MANIP,1923520,CDM,981,RC,23520,HCPCS,Outpatient,,,715.25,429.15,,607.96,85,,486.37,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,229.95,32.15,,183.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,572.41,80.03,,457.93,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,643.73,90,,514.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,229.95,32.15,,183.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,229.95,32.15,,183.96,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,629.42,88,,503.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,236.82,33.11,,189.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,229.95,643.73,
CLSD TX ULNAR SHAFT FX  W/O MANI,1925530,CDM,981,RC,25530,HCPCS,Outpatient,,,729.75,437.85,,620.29,85,,496.23,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,234.61,32.15,,187.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,584.02,80.03,,467.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,656.78,90,,525.42,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,234.61,32.15,,187.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,234.61,32.15,,187.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,642.18,88,,513.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,241.62,33.11,,193.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,234.61,656.78,
INSERT INTRAPERITONEAL CATH FOR DIALYS,1949420,CDM,981,RC,49421,HCPCS,Outpatient,,,734.75,440.85,,624.54,85,,499.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,236.22,32.15,,188.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,588.02,80.03,,470.42,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,3395.65,102,,,fee schedule,Pays at 102% of CMS APC rate,661.28,90,,529.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,236.22,32.15,,188.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,3395.65,100,,,fee schedule,Pays at 100% of CMS APC rate,236.22,32.15,,188.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,646.58,88,,517.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,243.28,33.11,,194.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,236.22,661.28,
"INCISION OF SOFT TISSUE ABSCESS, SUPERFI",1920000,CDM,981,RC,20005,HCPCS,Outpatient,,,737,442.2,,626.45,85,,501.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,236.95,32.15,,189.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,589.82,80.03,,471.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,663.3,90,,530.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,236.95,32.15,,189.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,,,,,Other,Not Separately reimbursable,236.95,32.15,,189.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,648.56,88,,518.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,244.02,33.11,,195.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,236.95,663.3,
CLOSED SCAPULAR FRACTURE W/O MAN,1923570,CDM,981,RC,23570,HCPCS,Outpatient,,,737,442.2,,626.45,85,,501.16,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,236.95,32.15,,189.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,589.82,80.03,,471.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,663.3,90,,530.64,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,236.95,32.15,,189.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,236.95,32.15,,189.56,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,648.56,88,,518.85,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,244.02,33.11,,195.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,236.95,663.3,
CLSD TX RADIAL HEAD FX W/O MAN,1924650,CDM,981,RC,24650,HCPCS,Outpatient,,,738,442.8,,627.3,85,,501.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,237.27,32.15,,189.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,590.62,80.03,,472.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,664.2,90,,531.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,237.27,32.15,,189.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,237.27,32.15,,189.82,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,649.44,88,,519.55,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,244.35,33.11,,195.48,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,237.27,664.2,
"CMPLX LAC 1.1-2.5 CM SCALP,ARMS,LEGS",1913120,CDM,981,RC,13120,HCPCS,Outpatient,,,743.25,445.95,,631.76,85,,505.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,238.95,32.15,,191.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,594.82,80.03,,475.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,668.93,90,,535.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,238.95,32.15,,191.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,238.95,32.15,,191.16,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,654.06,88,,523.25,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,246.09,33.11,,196.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,238.95,668.93,
"INT LAC 12.6-20.0 CM BD,SC",1912035,CDM,981,RC,12035,HCPCS,Outpatient,,,754.5,452.7,,641.33,85,,513.06,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,242.57,32.15,,194.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,603.83,80.03,,483.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,679.05,90,,543.24,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,242.57,32.15,,194.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,242.57,32.15,,194.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,663.96,88,,531.17,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,249.81,33.11,,199.85,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,242.57,679.05,
CT THORAX WITH AND  W/O DYE,8971251,CDM,972,RC,71270,HCPCS,Outpatient,,,768,460.8,,652.8,85,,522.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,246.91,32.15,,197.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,614.63,80.03,,491.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,172.88,102,,,fee schedule,Pays at 102% of CMS APC rate,691.2,90,,552.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,246.91,32.15,,197.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,172.88,100,,,fee schedule,Pays at 100% of CMS APC rate,246.91,32.15,,197.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,675.84,88,,540.67,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,254.28,33.11,,203.42,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,246.91,691.2,
CLSD TX RADIAL SHAF FX  W/O MANI,1925500,CDM,981,RC,25500,HCPCS,Outpatient,,,773.25,463.95,,657.26,85,,525.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,248.6,32.15,,198.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,618.83,80.03,,495.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,695.93,90,,556.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,248.6,32.15,,198.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,248.6,32.15,,198.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,680.46,88,,544.37,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,256.02,33.11,,204.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,248.6,695.93,
CLSD TX FX RADIUS & ULNA W/O MANI,1925560,CDM,981,RC,25560,HCPCS,Outpatient,,,774.25,464.55,,658.11,85,,526.49,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,248.92,32.15,,199.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,619.63,80.03,,495.7,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,696.83,90,,557.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,248.92,32.15,,199.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,248.92,32.15,,199.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,681.34,88,,545.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,256.35,33.11,,205.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,248.92,696.83,
FB REM MUSCLE COMPLEX,1920525,CDM,981,RC,20525,HCPCS,Outpatient,,,777.25,466.35,,660.66,85,,528.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,249.89,32.15,,199.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,622.03,80.03,,497.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2476.56,102,,,fee schedule,Pays at 102% of CMS APC rate,699.53,90,,559.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,249.89,32.15,,199.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2476.56,100,,,fee schedule,Pays at 100% of CMS APC rate,249.89,32.15,,199.91,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,683.98,88,,547.18,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,257.35,33.11,,205.88,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,249.89,699.53,
CLSD TX DIP OR PIP DISLOC W/MANIP,1926770,CDM,981,RC,26770,HCPCS,Outpatient,,,785.5,471.3,,667.68,85,,534.14,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,252.54,32.15,,202.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,628.64,80.03,,502.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,706.95,90,,565.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,252.54,32.15,,202.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,252.54,32.15,,202.03,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,691.24,88,,552.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,260.08,33.11,,208.06,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,252.54,706.95,
MRI BONE MARROW,8977084,CDM,972,RC,77084,HCPCS,Outpatient,,,788,472.8,,669.8,85,,535.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,253.34,32.15,,202.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,630.64,80.03,,504.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,223.87,102,,,fee schedule,Pays at 102% of CMS APC rate,709.2,90,,567.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,253.34,32.15,,202.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,223.87,100,,,fee schedule,Pays at 100% of CMS APC rate,253.34,32.15,,202.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,693.44,88,,554.75,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,260.91,33.11,,208.73,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,253.34,709.2,
CLSD TX PROXIMAL HUMERAL TUBEROSITY FX W,1923620,CDM,981,RC,23620,HCPCS,Outpatient,,,788.75,473.25,,670.44,85,,536.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,253.58,32.15,,202.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,631.24,80.03,,504.99,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,709.88,90,,567.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,253.58,32.15,,202.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,253.58,32.15,,202.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,694.1,88,,555.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,261.16,33.11,,208.93,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,253.58,709.88,
CMPLX LAC 1.1-2.5 CM FACE/NECK/HND/FT/AX,1913131,CDM,981,RC,13131,HCPCS,Outpatient,,,789.75,473.85,,671.29,85,,537.03,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,253.9,32.15,,203.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,632.04,80.03,,505.63,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,710.78,90,,568.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,253.9,32.15,,203.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,253.9,32.15,,203.12,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,694.98,88,,555.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,261.49,33.11,,209.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,253.9,710.78,
CMPLX LAC 2.6-7.5 CM TRK,1913101,CDM,981,RC,13101,HCPCS,Outpatient,,,798,478.8,,678.3,85,,542.64,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,256.56,32.15,,205.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,638.64,80.03,,510.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,718.2,90,,574.56,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,256.56,32.15,,205.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,256.56,32.15,,205.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,702.24,88,,561.79,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,264.22,33.11,,211.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,256.56,718.2,
"TX TARSAL BONE FX W/ MAN, EACH",1928455,CDM,981,RC,28455,HCPCS,Outpatient,,,803.25,481.95,,682.76,85,,546.21,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.24,32.15,,206.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,642.84,80.03,,514.27,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,722.93,90,,578.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.24,32.15,,206.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,258.24,32.15,,206.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,706.86,88,,565.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,265.96,33.11,,212.77,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.24,722.93,
EXPLORATION OF PENETRATING WOUND ABD/FLA,1920102,CDM,981,RC,20102,HCPCS,Outpatient,,,804.25,482.55,,683.61,85,,546.89,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,643.64,80.03,,514.91,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,723.83,90,,579.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,258.57,32.15,,206.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,707.74,88,,566.19,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,266.29,33.11,,213.03,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,258.57,723.83,
CLSD TX ULNA FX PROXIMAL W/O MANI,1924670,CDM,981,RC,24670,HCPCS,Outpatient,,,808.25,484.95,,687.01,85,,549.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,259.85,32.15,,207.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,646.84,80.03,,517.47,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,727.43,90,,581.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,259.85,32.15,,207.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,259.85,32.15,,207.88,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,711.26,88,,569.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,267.61,33.11,,214.09,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,259.85,727.43,
CLSD TX DISTAL TUFT FX W/MANIP,1926755,CDM,981,RC,26755,HCPCS,Outpatient,,,842.5,505.5,,716.13,85,,572.9,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,270.86,32.15,,216.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,674.25,80.03,,539.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,758.25,90,,606.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,270.86,32.15,,216.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,270.86,32.15,,216.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,741.4,88,,593.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,278.95,33.11,,223.16,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,270.86,758.25,
"CMPLX LAC 2.6-7.5 CM SCALP,ARMS,LEGS",1913121,CDM,981,RC,13121,HCPCS,Outpatient,,,844.5,506.7,,717.83,85,,574.26,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,271.51,32.15,,217.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,675.85,80.03,,540.68,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,760.05,90,,608.04,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,271.51,32.15,,217.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,271.51,32.15,,217.21,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,743.16,88,,594.53,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,279.61,33.11,,223.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,271.51,760.05,
INT LAC 12.5-20.0 CM,1912045,CDM,981,RC,12045,HCPCS,Outpatient,,,845.5,507.3,,718.68,85,,574.94,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,271.83,32.15,,217.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,676.65,80.03,,541.32,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,760.95,90,,608.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,271.83,32.15,,217.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,271.83,32.15,,217.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,744.04,88,,595.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,279.95,33.11,,223.96,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,271.83,760.95,
"CLSD TX METACARPAL FX W/O MANIP,EA",1926600,CDM,981,RC,26600,HCPCS,Outpatient,,,848.75,509.25,,721.44,85,,577.15,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,272.87,32.15,,218.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,679.25,80.03,,543.4,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,763.88,90,,611.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,272.87,32.15,,218.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,272.87,32.15,,218.3,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,746.9,88,,597.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,281.02,33.11,,224.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,272.87,763.88,
CLSD TX NAVICULAR FX W/O MANIP,1925622,CDM,981,RC,25622,HCPCS,Outpatient,,,855,513,,726.75,85,,581.4,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,274.88,32.15,,219.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,684.26,80.03,,547.41,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,769.5,90,,615.6,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,274.88,32.15,,219.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,274.88,32.15,,219.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,752.4,88,,601.92,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,283.09,33.11,,226.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,274.88,769.5,
"CLSD TX FX CARPAL BONE W/O MANIP,EA",1925630,CDM,981,RC,25630,HCPCS,Outpatient,,,866.25,519.75,,736.31,85,,589.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,278.5,32.15,,222.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,693.26,80.03,,554.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,779.63,90,,623.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,278.5,32.15,,222.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,278.5,32.15,,222.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,762.3,88,,609.84,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,286.82,33.11,,229.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,278.5,779.63,
INT LAC 20.1-30.0 CM BD SC,1912036,CDM,981,RC,12036,HCPCS,Outpatient,,,877.75,526.65,,746.09,85,,596.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,282.2,32.15,,225.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,702.46,80.03,,561.97,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,789.98,90,,631.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,282.2,32.15,,225.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,282.2,32.15,,225.76,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,772.42,88,,617.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,290.62,33.11,,232.5,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,282.2,789.98,
TRANSTRACH TRACHEOSTOMY,1931603,CDM,981,RC,31603,HCPCS,Outpatient,,,880.5,528.3,,748.43,85,,598.74,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,283.08,32.15,,226.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,704.66,80.03,,563.73,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1330.81,102,,,fee schedule,Pays at 102% of CMS APC rate,792.45,90,,633.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,283.08,32.15,,226.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1330.81,100,,,fee schedule,Pays at 100% of CMS APC rate,283.08,32.15,,226.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,774.84,88,,619.87,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,291.53,33.11,,233.22,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,283.08,792.45,
CLSD TX DIS FIBULA W/O MANIP,1927786,CDM,981,RC,27786,HCPCS,Outpatient,,,882.75,529.65,,750.34,85,,600.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,283.8,32.15,,227.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,706.46,80.03,,565.17,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,794.48,90,,635.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,283.8,32.15,,227.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,283.8,32.15,,227.04,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,776.82,88,,621.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,292.28,33.11,,233.82,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,283.8,794.48,
CLSD TX SHOULDER DISLOC W/MANIP W/O ANES,1923650,CDM,981,RC,23650,HCPCS,Outpatient,,,891.25,534.75,,757.56,85,,606.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,286.54,32.15,,229.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,713.27,80.03,,570.62,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,802.13,90,,641.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,286.54,32.15,,229.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,286.54,32.15,,229.23,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,784.3,88,,627.44,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,295.09,33.11,,236.07,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,286.54,802.13,
"CLSD TX METACARPAL FX W/MANIP,EA",1926605,CDM,981,RC,26605,HCPCS,Outpatient,,,901.5,540.9,,766.28,85,,613.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,289.83,32.15,,231.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,721.47,80.03,,577.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,811.35,90,,649.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,289.83,32.15,,231.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,289.83,32.15,,231.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,793.32,88,,634.66,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,298.49,33.11,,238.79,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,289.83,811.35,
"CMPLX LAC <1.1 CM NOSE,EARS,EYES,LIPS",1913150,CDM,981,RC,13151,HCPCS,Outpatient,,,907.75,544.65,,771.59,85,,617.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,291.84,32.15,,233.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,726.47,80.03,,581.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,816.98,90,,653.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,291.84,32.15,,233.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,291.84,32.15,,233.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,798.82,88,,639.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,300.56,33.11,,240.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,291.84,816.98,
"CMPLX LAC 1.1-2.5 CM N,E,E,L",1913151,CDM,981,RC,13151,HCPCS,Outpatient,,,907.75,544.65,,771.59,85,,617.27,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,291.84,32.15,,233.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,726.47,80.03,,581.18,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,816.98,90,,653.58,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,291.84,32.15,,233.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,291.84,32.15,,233.47,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,798.82,88,,639.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,300.56,33.11,,240.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,291.84,816.98,
CLSD TX PATELLAR FX W/O MAN,1927520,CDM,981,RC,27520,HCPCS,Outpatient,,,909.75,545.85,,773.29,85,,618.63,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,292.48,32.15,,233.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,728.07,80.03,,582.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,818.78,90,,655.02,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,292.48,32.15,,233.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,292.48,32.15,,233.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,800.58,88,,640.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,301.22,33.11,,240.98,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,292.48,818.78,
CRITICIAL CARE 1ST HR,1499291,CDM,981,RC,99291,HCPCS,Outpatient,,,915.75,549.45,,778.39,85,,622.71,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,294.41,32.15,,235.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,732.87,80.03,,586.3,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,736.01,102,,,fee schedule,Pays at 102% of CMS APC rate,824.18,90,,659.34,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,294.41,32.15,,235.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,736.01,100,,,fee schedule,Pays at 100% of CMS APC rate,294.41,32.15,,235.53,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,805.86,88,,644.69,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,303.2,33.11,,242.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,294.41,824.18,
CLSD TX ULNAR STYLOID FX,1925650,CDM,981,RC,25650,HCPCS,Outpatient,,,923.25,553.95,,784.76,85,,627.81,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,296.82,32.15,,237.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,738.88,80.03,,591.1,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,830.93,90,,664.74,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,296.82,32.15,,237.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,296.82,32.15,,237.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,812.46,88,,649.97,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,305.69,33.11,,244.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,296.82,830.93,
CLSD TX BIMALLEOLAR ANKLE FX W/O MANIP,1927808,CDM,981,RC,27808,HCPCS,Outpatient,,,925.25,555.15,,786.46,85,,629.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,297.47,32.15,,237.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,740.48,80.03,,592.38,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,832.73,90,,666.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,297.47,32.15,,237.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,297.47,32.15,,237.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,814.22,88,,651.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,306.35,33.11,,245.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,297.47,832.73,
"CLSD TX FINGER FRACTURE W/MANIP,EA",1926725,CDM,981,RC,26725,HCPCS,Outpatient,,,936.75,562.05,,796.24,85,,636.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.17,32.15,,240.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,749.68,80.03,,599.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,843.08,90,,674.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.17,32.15,,240.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,301.17,32.15,,240.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,824.34,88,,659.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.16,33.11,,248.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.17,843.08,
CLSD TX FX MED MALLEOLUS W/O MANIP,1927760,CDM,981,RC,27760,HCPCS,Outpatient,,,936.75,562.05,,796.24,85,,636.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.17,32.15,,240.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,749.68,80.03,,599.74,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,843.08,90,,674.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.17,32.15,,240.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,301.17,32.15,,240.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,824.34,88,,659.47,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.16,33.11,,248.13,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.17,843.08,
CLSD TX MCP DISLOCATION W/MANIP W/O ANES,1926700,CDM,981,RC,26700,HCPCS,Outpatient,,,938.75,563.25,,797.94,85,,638.35,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,301.81,32.15,,241.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,751.28,80.03,,601.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,844.88,90,,675.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,301.81,32.15,,241.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,301.81,32.15,,241.45,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,826.1,88,,660.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,310.82,33.11,,248.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,301.81,844.88,
BIOPSY OF ANORECTAL WALL,1945100,CDM,981,RC,45100,HCPCS,Outpatient,,,941.75,565.05,,800.49,85,,640.39,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,302.77,32.15,,242.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,753.68,80.03,,602.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2463.35,102,,,fee schedule,Pays at 102% of CMS APC rate,847.58,90,,678.06,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,302.77,32.15,,242.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2463.35,100,,,fee schedule,Pays at 100% of CMS APC rate,302.77,32.15,,242.22,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,828.74,88,,662.99,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,311.81,33.11,,249.45,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,302.77,847.58,
CLSD TX AC DISLOCATION W/MANIP,1923545,CDM,981,RC,23545,HCPCS,Outpatient,,,945,567,,803.25,85,,642.6,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,303.82,32.15,,243.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,756.28,80.03,,605.02,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,850.5,90,,680.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,303.82,32.15,,243.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,303.82,32.15,,243.06,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,831.6,88,,665.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,312.89,33.11,,250.31,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,303.82,850.5,
CLSD TX PROXIMAL HUMERAL FX W/O MANIP,1923600,CDM,981,RC,23600,HCPCS,Outpatient,,,946,567.6,,804.1,85,,643.28,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,304.14,32.15,,243.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,757.08,80.03,,605.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,851.4,90,,681.12,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,304.14,32.15,,243.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,304.14,32.15,,243.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,832.48,88,,665.98,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,313.22,33.11,,250.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,304.14,851.4,
CLSD TX DISTAL RADIAL FX W/O MAN,1925600,CDM,981,RC,25600,HCPCS,Outpatient,,,952.25,571.35,,809.41,85,,647.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,306.15,32.15,,244.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,762.09,80.03,,609.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,857.03,90,,685.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,306.15,32.15,,244.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,306.15,32.15,,244.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,837.98,88,,670.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,315.29,33.11,,252.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,306.15,857.03,
CLSD TX CARPO-MCFX DISLOC(N/ THUMB W/MAN,1926670,CDM,981,RC,26670,HCPCS,Outpatient,,,952.25,571.35,,809.41,85,,647.53,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,306.15,32.15,,244.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,762.09,80.03,,609.67,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,857.03,90,,685.62,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,306.15,32.15,,244.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,306.15,32.15,,244.92,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,837.98,88,,670.38,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,315.29,33.11,,252.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,306.15,857.03,
INT LAC 12.6-20.0 CM,1912055,CDM,981,RC,12055,HCPCS,Outpatient,,,959.5,575.7,,815.58,85,,652.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,308.48,32.15,,246.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,767.89,80.03,,614.31,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,863.55,90,,690.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,308.48,32.15,,246.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,308.48,32.15,,246.78,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,844.36,88,,675.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,317.69,33.11,,254.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,308.48,863.55,
INT LAC 20.1-30.0 CM NHF,1912046,CDM,981,RC,12046,HCPCS,Outpatient,,,971.75,583.05,,825.99,85,,660.79,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,312.42,32.15,,249.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,777.69,80.03,,622.15,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,874.58,90,,699.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,312.42,32.15,,249.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,312.42,32.15,,249.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,855.14,88,,684.11,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,321.75,33.11,,257.4,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,312.42,874.58,
CLSD TX TIB FX W/O MAN,1927750,CDM,981,RC,27750,HCPCS,Outpatient,,,981.25,588.75,,834.06,85,,667.25,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,315.47,32.15,,252.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,785.29,80.03,,628.23,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,883.13,90,,706.5,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,315.47,32.15,,252.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,315.47,32.15,,252.38,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,863.5,88,,690.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,324.89,33.11,,259.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,315.47,883.13,
"REMOVAL OF F.B. FOOT,DEEP",1928192,CDM,981,RC,28192,HCPCS,Outpatient,,,984.25,590.55,,836.61,85,,669.29,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,316.44,32.15,,253.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,787.7,80.03,,630.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,885.83,90,,708.66,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,316.44,32.15,,253.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,316.44,32.15,,253.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,866.14,88,,692.91,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,325.89,33.11,,260.71,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,316.44,885.83,
"CMPLX LAC 2.6-7.5 CM FACE,H,F",1913132,CDM,981,RC,13132,HCPCS,Outpatient,,,995.75,597.45,,846.39,85,,677.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,796.9,80.03,,637.52,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,896.18,90,,716.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,320.13,32.15,,256.1,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,876.26,88,,701.01,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,329.69,33.11,,263.75,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,320.13,896.18,
CLSD TX TREAT HUMERAL FX W/O MAN,1924500,CDM,981,RC,24500,HCPCS,Outpatient,,,1006,603.6,,855.1,85,,684.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,323.43,32.15,,258.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,805.1,80.03,,644.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,905.4,90,,724.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,323.43,32.15,,258.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,323.43,32.15,,258.74,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,885.28,88,,708.22,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,333.09,33.11,,266.47,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,323.43,905.4,
CLSD TX CLAVICLE FX W/MANIP,1923505,CDM,981,RC,23505,HCPCS,Outpatient,,,1023.5,614.1,,869.98,85,,695.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,329.06,32.15,,263.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,819.11,80.03,,655.29,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,921.15,90,,736.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,329.06,32.15,,263.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,329.06,32.15,,263.25,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,900.68,88,,720.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,338.88,33.11,,271.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,329.06,921.15,
CLSD TX PATELLAR DISLOC W/O ANEST,1927560,CDM,981,RC,27560,HCPCS,Outpatient,,,1027.75,616.65,,873.59,85,,698.87,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,330.42,32.15,,264.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,822.51,80.03,,658.01,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,924.98,90,,739.98,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,330.42,32.15,,264.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,330.42,32.15,,264.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,904.42,88,,723.54,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,340.29,33.11,,272.23,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,330.42,924.98,
TX CLSD ELBOW DISLOC W/O ANEST,1924600,CDM,981,RC,24600,HCPCS,Outpatient,,,1033,619.8,,878.05,85,,702.44,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,332.11,32.15,,265.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,826.71,80.03,,661.37,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,929.7,90,,743.76,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,332.11,32.15,,265.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,332.11,32.15,,265.69,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,909.04,88,,727.23,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,342.03,33.11,,273.62,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,332.11,929.7,
CLSD TX ARTICULAR FX W/MAN,1926742,CDM,981,RC,26742,HCPCS,Outpatient,,,1035,621,,879.75,85,,703.8,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,332.75,32.15,,266.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,828.31,80.03,,662.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,931.5,90,,745.2,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,332.75,32.15,,266.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,332.75,32.15,,266.2,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,910.8,88,,728.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,342.69,33.11,,274.15,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,332.75,931.5,
CLSD TX CARPO-M DISLOC THUMB W/MANI,1926641,CDM,981,RC,26641,HCPCS,Outpatient,,,1056.75,634.05,,898.24,85,,718.59,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,339.75,32.15,,271.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,845.72,80.03,,676.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,951.08,90,,760.86,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,339.75,32.15,,271.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,339.75,32.15,,271.8,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,929.94,88,,743.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,349.89,33.11,,279.91,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,339.75,951.08,
CLSD TX DISTAL HUMERAL FX W/O MANIP,1924530,CDM,981,RC,24530,HCPCS,Outpatient,,,1063,637.8,,903.55,85,,722.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,341.75,32.15,,273.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,850.72,80.03,,680.58,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,956.7,90,,765.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,341.75,32.15,,273.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,341.75,32.15,,273.4,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,935.44,88,,748.35,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,351.96,33.11,,281.57,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,341.75,956.7,
INT LAC 20.1-30.0 CM,1912056,CDM,981,RC,12056,HCPCS,Outpatient,,,1076.5,645.9,,915.03,85,,732.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,346.09,32.15,,276.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,861.52,80.03,,689.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,357.66,102,,,fee schedule,Pays at 102% of CMS APC rate,968.85,90,,775.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,346.09,32.15,,276.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,357.66,100,,,fee schedule,Pays at 100% of CMS APC rate,346.09,32.15,,276.87,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,947.32,88,,757.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,356.43,33.11,,285.14,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,346.09,968.85,
CLSD TX PROXIMAL HUMERAL TUBEROSITY FX W,1923625,CDM,981,RC,23625,HCPCS,Outpatient,,,1086.75,652.05,,923.74,85,,738.99,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,349.39,32.15,,279.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,869.73,80.03,,695.78,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,978.08,90,,782.46,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,349.39,32.15,,279.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,349.39,32.15,,279.51,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,956.34,88,,765.07,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,359.82,33.11,,287.86,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,349.39,978.08,
EXPLORATION OF PENETRATING WOUND EXTREMI,1920103,CDM,981,RC,20103,HCPCS,Outpatient,,,1097,658.2,,932.45,85,,745.96,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,352.69,32.15,,282.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,877.93,80.03,,702.34,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,987.3,90,,789.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,352.69,32.15,,282.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,352.69,32.15,,282.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,965.36,88,,772.29,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,363.22,33.11,,290.58,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,352.69,987.3,
"CMPLX LAC 2.6-7.5 CM N,E,E,L",1913152,CDM,981,RC,13152,HCPCS,Outpatient,,,1101.25,660.75,,936.06,85,,748.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,354.05,32.15,,283.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,881.33,80.03,,705.06,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,991.13,90,,792.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,354.05,32.15,,283.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,354.05,32.15,,283.24,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,969.1,88,,775.28,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,364.62,33.11,,291.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,354.05,991.13,
CLSD TX ANKLE DISLOC W/O ANEST,1927840,CDM,981,RC,27840,HCPCS,Outpatient,,,1141.5,684.9,,970.28,85,,776.22,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,366.99,32.15,,293.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,913.54,80.03,,730.83,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1027.35,90,,821.88,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,366.99,32.15,,293.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,366.99,32.15,,293.59,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1004.52,88,,803.62,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,377.95,33.11,,302.36,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,366.99,1027.35,
INT LAC REPAIR>30.0 CM NHF,1912047,CDM,981,RC,12047,HCPCS,Outpatient,,,1158.25,694.95,,984.51,85,,787.61,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,372.38,32.15,,297.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,926.95,80.03,,741.56,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1654.58,102,,,fee schedule,Pays at 102% of CMS APC rate,1042.43,90,,833.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,372.38,32.15,,297.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1654.58,100,,,fee schedule,Pays at 100% of CMS APC rate,372.38,32.15,,297.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1019.26,88,,815.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,383.5,33.11,,306.8,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,372.38,1042.43,
"REMOVAL OF F.B. FOOT,COMP",1928193,CDM,981,RC,28193,HCPCS,Outpatient,,,1161.25,696.75,,987.06,85,,789.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,373.34,32.15,,298.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,929.35,80.03,,743.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1045.13,90,,836.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,373.34,32.15,,298.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,373.34,32.15,,298.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1021.9,88,,817.52,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,384.49,33.11,,307.59,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,373.34,1045.13,
CLSD TX DIS FIBULA W/MANIP,1927788,CDM,981,RC,27788,HCPCS,Outpatient,,,1191.25,714.75,,1012.56,85,,810.05,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,382.99,32.15,,306.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,953.36,80.03,,762.69,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1072.13,90,,857.7,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,382.99,32.15,,306.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,382.99,32.15,,306.39,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1048.3,88,,838.64,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,394.42,33.11,,315.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,382.99,1072.13,
CLSD TX CARPO-MCFX DISLOC THUMB W/MANI,1926645,CDM,981,RC,26645,HCPCS,Outpatient,,,1213,727.8,,1031.05,85,,824.84,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,389.98,32.15,,311.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,970.76,80.03,,776.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1091.7,90,,873.36,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,389.98,32.15,,311.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,389.98,32.15,,311.98,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1067.44,88,,853.95,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,401.62,33.11,,321.3,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,389.98,1091.7,
CLSD TX DISTAL RADIOULNAR DISLOC W/MANI,1925675,CDM,981,RC,25675,HCPCS,Outpatient,,,1218.25,730.95,,1035.51,85,,828.41,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,391.67,32.15,,313.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,974.97,80.03,,779.98,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1096.43,90,,877.14,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,391.67,32.15,,313.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,391.67,32.15,,313.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1072.06,88,,857.65,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,403.36,33.11,,322.69,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,391.67,1096.43,
SHOULDER DISLOCATION,1911044,CDM,981,RC,23665,HCPCS,Outpatient,,,1226.5,735.9,,1042.53,85,,834.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,394.32,32.15,,315.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.57,80.03,,785.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1103.85,90,,883.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,394.32,32.15,,315.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,394.32,32.15,,315.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1079.32,88,,863.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,406.09,33.11,,324.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,394.32,1103.85,
CLSD TX FX RADIAL HD W/MANIP,1924655,CDM,981,RC,24655,HCPCS,Outpatient,,,1226.5,735.9,,1042.53,85,,834.02,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,394.32,32.15,,315.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,981.57,80.03,,785.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1103.85,90,,883.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,394.32,32.15,,315.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,394.32,32.15,,315.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1079.32,88,,863.46,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,406.09,33.11,,324.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,394.32,1103.85,
CLSD TX POST HIP DISLOC,1927265,CDM,981,RC,27265,HCPCS,Outpatient,,,1239,743.4,,1053.15,85,,842.52,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,398.34,32.15,,318.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,991.57,80.03,,793.26,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1115.1,90,,892.08,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,398.34,32.15,,318.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,398.34,32.15,,318.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1090.32,88,,872.26,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,410.23,33.11,,328.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,398.34,1115.1,
"CLSD TX RADIOCARP DISL,ONE OR MORE,W/MAN",1925660,CDM,981,RC,25660,HCPCS,Outpatient,,,1274,764.4,,1082.9,85,,866.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,409.59,32.15,,327.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1019.58,80.03,,815.66,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1146.6,90,,917.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,409.59,32.15,,327.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,409.59,32.15,,327.67,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1121.12,88,,896.9,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,421.82,33.11,,337.46,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,409.59,1146.6,
CLSD TX BIMALLEOLAR ANKLE FX W/MANIP,1927810,CDM,981,RC,27810,HCPCS,Outpatient,,,1311.25,786.75,,1114.56,85,,891.65,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,421.57,32.15,,337.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1049.39,80.03,,839.51,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1180.13,90,,944.1,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,421.57,32.15,,337.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,421.57,32.15,,337.26,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1153.9,88,,923.12,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,434.15,33.11,,347.32,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,421.57,1180.13,
CLSD TX FX MED MALLEOLUS W/MANIP,1927762,CDM,981,RC,27762,HCPCS,Outpatient,,,1331,798.6,,1131.35,85,,905.08,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,427.92,32.15,,342.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1065.2,80.03,,852.16,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1197.9,90,,958.32,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,427.92,32.15,,342.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,427.92,32.15,,342.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1171.28,88,,937.02,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,440.69,33.11,,352.55,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,427.92,1197.9,
CLSD TX TRIMALLEOLAR ANKLE FX W/MANIP,1927818,CDM,981,RC,27818,HCPCS,Outpatient,,,1346.5,807.9,,1144.53,85,,915.62,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,432.9,32.15,,346.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1077.6,80.03,,862.08,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1211.85,90,,969.48,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,432.9,32.15,,346.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,432.9,32.15,,346.32,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1184.92,88,,947.94,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,445.83,33.11,,356.66,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,432.9,1211.85,
DEBRIDE SKIN/BONE AT FRACTURE SITE,1911012,CDM,981,RC,11012,HCPCS,Outpatient,,,1348.5,809.1,,1146.23,85,,916.98,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,433.54,32.15,,346.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1079.2,80.03,,863.36,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2476.56,102,,,fee schedule,Pays at 102% of CMS APC rate,1213.65,90,,970.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,433.54,32.15,,346.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2476.56,100,,,fee schedule,Pays at 100% of CMS APC rate,433.54,32.15,,346.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1186.68,88,,949.34,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,446.49,33.11,,357.19,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,433.54,1213.65,
PINCH GRAFT UP TO 2 CM DIAMETER,1915050,CDM,981,RC,15050,HCPCS,Outpatient,,,1383.75,830.25,,1176.19,85,,940.95,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,444.88,32.15,,355.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1107.42,80.03,,885.94,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,556.95,102,,,fee schedule,Pays at 102% of CMS APC rate,1245.38,90,,996.3,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,444.88,32.15,,355.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,556.95,100,,,fee schedule,Pays at 100% of CMS APC rate,444.88,32.15,,355.9,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1217.7,88,,974.16,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,458.16,33.11,,366.53,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,444.88,1245.38,
CLSD TX ULNAR SHAFT FX  W/MANI,1925535,CDM,981,RC,25535,HCPCS,Outpatient,,,1400.25,840.15,,1190.21,85,,952.17,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,450.18,32.15,,360.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1120.62,80.03,,896.5,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1260.23,90,,1008.18,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,450.18,32.15,,360.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,450.18,32.15,,360.14,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1232.22,88,,985.78,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,463.62,33.11,,370.9,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,450.18,1260.23,
CLSD TX RADIAL SHAFT FX  W/MANI,1925505,CDM,981,RC,25505,HCPCS,Outpatient,,,1418,850.8,,1205.3,85,,964.24,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,455.89,32.15,,364.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1134.83,80.03,,907.86,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1276.2,90,,1020.96,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,455.89,32.15,,364.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,455.89,32.15,,364.71,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1247.84,88,,998.27,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,469.5,33.11,,375.6,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,455.89,1276.2,
CLSD TX FX RADIUS & ULNA W/MANI,1925565,CDM,981,RC,25565,HCPCS,Outpatient,,,1450,870,,1232.5,85,,986,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,466.18,32.15,,372.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1160.44,80.03,,928.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1305,90,,1044,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,466.18,32.15,,372.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,466.18,32.15,,372.94,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1276,88,,1020.8,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,480.1,33.11,,384.08,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,466.18,1305,
CLSD TX KNEE DISLOC,1927550,CDM,981,RC,27550,HCPCS,Outpatient,,,1462.5,877.5,,1243.13,85,,994.5,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,470.19,32.15,,376.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1170.44,80.03,,936.35,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,198.45,102,,,fee schedule,Pays at 102% of CMS APC rate,1316.25,90,,1053,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,470.19,32.15,,376.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,198.45,100,,,fee schedule,Pays at 100% of CMS APC rate,470.19,32.15,,376.15,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1287,88,,1029.6,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,484.23,33.11,,387.38,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,470.19,1316.25,
EX TEND REP/SPLINT MALLET FINGER,1926432,CDM,981,RC,26432,HCPCS,Outpatient,,,1514.25,908.55,,1287.11,85,,1029.69,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,486.83,32.15,,389.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1211.85,80.03,,969.48,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1362.83,90,,1090.26,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,486.83,32.15,,389.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,486.83,32.15,,389.46,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1332.54,88,,1066.03,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,501.37,33.11,,401.1,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,486.83,1362.83,
CLSD TX TIBIAL FX W/MANIP,1927752,CDM,981,RC,27752,HCPCS,Outpatient,,,1541,924.6,,1309.85,85,,1047.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,495.43,32.15,,396.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1233.26,80.03,,986.61,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1386.9,90,,1109.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,495.43,32.15,,396.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,495.43,32.15,,396.34,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1356.08,88,,1084.86,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,510.23,33.11,,408.18,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,495.43,1386.9,
CLSD TX DISTAL RADIAL FX W/MAN,1925605,CDM,981,RC,25605,HCPCS,Outpatient,,,1584.5,950.7,,1346.83,85,,1077.46,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,509.42,32.15,,407.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1268.08,80.03,,1014.46,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1426.05,90,,1140.84,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,509.42,32.15,,407.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,509.42,32.15,,407.54,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1394.36,88,,1115.49,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,524.63,33.11,,419.7,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,509.42,1426.05,
MRI BREAST BIOPSY,8919085,CDM,972,RC,19085,HCPCS,Outpatient,,,1657.5,994.5,,1408.88,85,,1127.1,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,532.89,32.15,,426.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1326.5,80.03,,1061.2,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1437.62,102,,,fee schedule,Pays at 102% of CMS APC rate,1491.75,90,,1193.4,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,532.89,32.15,,426.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1437.62,100,,,fee schedule,Pays at 100% of CMS APC rate,532.89,32.15,,426.31,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1458.6,88,,1166.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,548.8,33.11,,439.04,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,532.89,1491.75,
REPAIR EXT TENDON HAND,1926410,CDM,981,RC,26410,HCPCS,Outpatient,,,1716,1029.6,,1458.6,85,,1166.88,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,551.69,32.15,,441.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1373.31,80.03,,1098.65,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1544.4,90,,1235.52,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,551.69,32.15,,441.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,551.69,32.15,,441.35,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1510.08,88,,1208.06,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,568.17,33.11,,454.54,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,551.69,1544.4,
REPAIR EXT TEND FINGER,1926418,CDM,981,RC,26418,HCPCS,Outpatient,,,1751.25,1050.75,,1488.56,85,,1190.85,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,563.03,32.15,,450.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1401.53,80.03,,1121.22,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,1375.28,102,,,fee schedule,Pays at 102% of CMS APC rate,1576.13,90,,1260.9,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,563.03,32.15,,450.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1375.28,100,,,fee schedule,Pays at 100% of CMS APC rate,563.03,32.15,,450.42,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1541.1,88,,1232.88,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,579.84,33.11,,463.87,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,563.03,1576.13,
EXPLORATION OF PENETRATING WOUND NECK,1920100,CDM,981,RC,20100,HCPCS,Outpatient,,,1924,1154.4,,1635.4,85,,1308.32,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,618.57,32.15,,494.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1539.78,80.03,,1231.82,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,437.94,102,,,fee schedule,Pays at 102% of CMS APC rate,1731.6,90,,1385.28,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,618.57,32.15,,494.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,437.94,100,,,fee schedule,Pays at 100% of CMS APC rate,618.57,32.15,,494.86,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,1693.12,88,,1354.5,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,637.04,33.11,,509.63,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,618.57,1731.6,
THORACOTOMY W/ CARDIAC MASSAGE,1932160,CDM,981,RC,32160,HCPCS,Outpatient,,,2511,1506.6,,2134.35,85,,1707.48,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,807.29,32.15,,645.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2009.55,80.03,,1607.64,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2511,102,,,fee schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2259.9,90,,1807.92,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,807.29,32.15,,645.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2511,100,,,fee schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,807.29,32.15,,645.83,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2209.68,88,,1767.74,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,831.39,33.11,,665.11,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,807.29,2259.9,
Vaginal delivery,1959409,CDM,981,RC,59409,HCPCS,Outpatient,,,2595.75,1557.45,,2206.39,85,,1765.11,percent of total billed charges,Pays at 85% of total Billed charges for Outpatient setting,834.53,32.15,,667.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2077.38,80.03,,1661.9,percent of total billed charges,Pays at 80.03% of total billed charges for outpatient setting,2710.67,102,,,fee schedule,Pays at 102% of CMS APC rate,2336.18,90,,1868.94,percent of total billed charges,Pays at 90% of total billed charges for outpatient setting,834.53,32.15,,667.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2710.67,100,,,fee schedule,Pays at 100% of CMS APC rate,834.53,32.15,,667.62,percent of total billed charges,Pays at 32.15% of total billed charges for Outpatient Setting,2284.26,88,,1827.41,percent of total billed charges,Pays at 88% of total billed charges for Outpatient Setting,859.45,33.11,,687.56,percent of total billed charges,Pays at 33.11% of total billed charges for Outpatient Setting,834.53,2336.18,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,114255.4,100,CUSTOM-DRG,91404.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,224427.61,102,MS-DRG,179542.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,114255.4,100,CUSTOM-DRG,91404.32,Case rate,100% of GA Medicaid ,220027.07,100,MS-DRG,176021.66,Case rate,100% of Medicare MS-DRG,114255.4,100,CUSTOM-DRG,91404.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,114255.4,100,CUSTOM-DRG,91404.32,Case rate,100% of GA Medicaid ,114255.4,224427.61,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,76933.16,100,CUSTOM-DRG,61546.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,101404.28,102,MS-DRG,81123.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,76933.16,100,CUSTOM-DRG,61546.53,Case rate,100% of GA Medicaid ,99415.96,100,MS-DRG,79532.77,Case rate,100% of Medicare MS-DRG,76933.16,100,CUSTOM-DRG,61546.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,76933.16,100,CUSTOM-DRG,61546.53,Case rate,100% of GA Medicaid ,76933.16,101404.28,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,113442.1,100,CUSTOM-DRG,90753.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,176572.37,102,MS-DRG,141257.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,113442.1,100,CUSTOM-DRG,90753.68,Case rate,100% of GA Medicaid ,173110.17,100,MS-DRG,138488.14,Case rate,100% of Medicare MS-DRG,113442.1,100,CUSTOM-DRG,90753.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,113442.1,100,CUSTOM-DRG,90753.68,Case rate,100% of GA Medicaid ,113442.1,176572.37,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,81717.69,100,CUSTOM-DRG,65374.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,121743.77,102,MS-DRG,97395.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,81717.69,100,CUSTOM-DRG,65374.15,Case rate,100% of GA Medicaid ,119356.64,100,MS-DRG,95485.31,Case rate,100% of Medicare MS-DRG,81717.69,100,CUSTOM-DRG,65374.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,81717.69,100,CUSTOM-DRG,65374.15,Case rate,100% of GA Medicaid ,81717.69,121743.77,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,170108.58,100,CUSTOM-DRG,136086.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,85717.55,102,MS-DRG,68574.04,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,170108.58,100,CUSTOM-DRG,136086.86,Case rate,100% of GA Medicaid ,84036.81,100,MS-DRG,67229.45,Case rate,100% of Medicare MS-DRG,170108.58,100,CUSTOM-DRG,136086.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,170108.58,100,CUSTOM-DRG,136086.86,Case rate,100% of GA Medicaid ,84036.81,170108.58,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,77507.68,100,CUSTOM-DRG,62006.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,40058.66,102,MS-DRG,32046.93,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,77507.68,100,CUSTOM-DRG,62006.14,Case rate,100% of GA Medicaid ,39273.2,100,MS-DRG,31418.56,Case rate,100% of Medicare MS-DRG,77507.68,100,CUSTOM-DRG,62006.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,77507.68,100,CUSTOM-DRG,62006.14,Case rate,100% of GA Medicaid ,39273.2,77507.68,
LUNG TRANSPLANT,7,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,101588.96,102,MS-DRG,81271.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,99597.02,100,MS-DRG,79677.62,Case rate,100% of Medicare MS-DRG,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,55328.52,101588.96,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,49122.36,100,CUSTOM-DRG,39297.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,43576.82,102,MS-DRG,34861.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,49122.36,100,CUSTOM-DRG,39297.89,Case rate,100% of GA Medicaid ,42722.37,100,MS-DRG,34177.9,Case rate,100% of Medicare MS-DRG,49122.36,100,CUSTOM-DRG,39297.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,49122.36,100,CUSTOM-DRG,39297.89,Case rate,100% of GA Medicaid ,42722.37,49122.36,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27198.6,100,CUSTOM-DRG,21758.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,39865.7,102,MS-DRG,31892.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27198.6,100,CUSTOM-DRG,21758.88,Case rate,100% of GA Medicaid ,39084.02,100,MS-DRG,31267.22,Case rate,100% of Medicare MS-DRG,27198.6,100,CUSTOM-DRG,21758.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27198.6,100,CUSTOM-DRG,21758.88,Case rate,100% of GA Medicaid ,27198.6,39865.7,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24073.92,100,CUSTOM-DRG,19259.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,42703.91,102,MS-DRG,34163.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,24073.92,100,CUSTOM-DRG,19259.14,Case rate,100% of GA Medicaid ,41866.58,100,MS-DRG,33493.26,Case rate,100% of Medicare MS-DRG,24073.92,100,CUSTOM-DRG,19259.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24073.92,100,CUSTOM-DRG,19259.14,Case rate,100% of GA Medicaid ,24073.92,42703.91,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23321.56,100,CUSTOM-DRG,18657.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,33168.14,102,MS-DRG,26534.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,23321.56,100,CUSTOM-DRG,18657.25,Case rate,100% of GA Medicaid ,32517.78,100,MS-DRG,26014.22,Case rate,100% of Medicare MS-DRG,23321.56,100,CUSTOM-DRG,18657.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23321.56,100,CUSTOM-DRG,18657.25,Case rate,100% of GA Medicaid ,23321.56,33168.14,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11787.93,100,CUSTOM-DRG,9430.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22242.66,102,MS-DRG,17794.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11787.93,100,CUSTOM-DRG,9430.34,Case rate,100% of GA Medicaid ,21806.53,100,MS-DRG,17445.22,Case rate,100% of Medicare MS-DRG,11787.93,100,CUSTOM-DRG,9430.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11787.93,100,CUSTOM-DRG,9430.34,Case rate,100% of GA Medicaid ,11787.93,22242.66,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,137432.91,100,CUSTOM-DRG,109946.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,94917.91,102,MS-DRG,75934.33,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,137432.91,100,CUSTOM-DRG,109946.33,Case rate,100% of GA Medicaid ,93056.77,100,MS-DRG,74445.42,Case rate,100% of Medicare MS-DRG,137432.91,100,CUSTOM-DRG,109946.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,137432.91,100,CUSTOM-DRG,109946.33,Case rate,100% of GA Medicaid ,93056.77,137432.91,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,39323.37,100,CUSTOM-DRG,31458.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,51157.22,102,MS-DRG,40925.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,39323.37,100,CUSTOM-DRG,31458.7,Case rate,100% of GA Medicaid ,50154.14,100,MS-DRG,40123.31,Case rate,100% of Medicare MS-DRG,39323.37,100,CUSTOM-DRG,31458.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,39323.37,100,CUSTOM-DRG,31458.7,Case rate,100% of GA Medicaid ,39323.37,51157.22,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17901.56,100,CUSTOM-DRG,14321.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,51157.22,102,MS-DRG,40925.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17901.56,100,CUSTOM-DRG,14321.25,Case rate,100% of GA Medicaid ,50154.14,100,MS-DRG,40123.31,Case rate,100% of Medicare MS-DRG,17901.56,100,CUSTOM-DRG,14321.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17901.56,100,CUSTOM-DRG,14321.25,Case rate,100% of GA Medicaid ,17901.56,51157.22,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,305127.15,102,MS-DRG,244101.72,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,299144.26,100,MS-DRG,239315.41,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,299144.26,305127.15,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,66201.28,102,MS-DRG,52961.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,64903.22,100,MS-DRG,51922.58,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,64903.22,66201.28,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,54932.39,100,CUSTOM-DRG,43945.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,70001.85,102,MS-DRG,56001.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,54932.39,100,CUSTOM-DRG,43945.91,Case rate,100% of GA Medicaid ,68629.26,100,MS-DRG,54903.41,Case rate,100% of Medicare MS-DRG,54932.39,100,CUSTOM-DRG,43945.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,54932.39,100,CUSTOM-DRG,43945.91,Case rate,100% of GA Medicaid ,54932.39,70001.85,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,34360.44,100,CUSTOM-DRG,27488.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,50862.39,102,MS-DRG,40689.91,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,34360.44,100,CUSTOM-DRG,27488.35,Case rate,100% of GA Medicaid ,49865.09,100,MS-DRG,39892.07,Case rate,100% of Medicare MS-DRG,34360.44,100,CUSTOM-DRG,27488.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,34360.44,100,CUSTOM-DRG,27488.35,Case rate,100% of GA Medicaid ,34360.44,50862.39,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23585.27,100,CUSTOM-DRG,18868.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32487.36,102,MS-DRG,25989.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,23585.27,100,CUSTOM-DRG,18868.22,Case rate,100% of GA Medicaid ,31850.35,100,MS-DRG,25480.28,Case rate,100% of Medicare MS-DRG,23585.27,100,CUSTOM-DRG,18868.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23585.27,100,CUSTOM-DRG,18868.22,Case rate,100% of GA Medicaid ,23585.27,32487.36,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,32496.71,100,CUSTOM-DRG,25997.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,46948.38,102,MS-DRG,37558.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,32496.71,100,CUSTOM-DRG,25997.37,Case rate,100% of GA Medicaid ,46027.82,100,MS-DRG,36822.26,Case rate,100% of Medicare MS-DRG,32496.71,100,CUSTOM-DRG,25997.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32496.71,100,CUSTOM-DRG,25997.37,Case rate,100% of GA Medicaid ,32496.71,46948.38,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17810.15,100,CUSTOM-DRG,14248.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,31378.42,102,MS-DRG,25102.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17810.15,100,CUSTOM-DRG,14248.12,Case rate,100% of GA Medicaid ,30763.16,100,MS-DRG,24610.53,Case rate,100% of Medicare MS-DRG,17810.15,100,CUSTOM-DRG,14248.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17810.15,100,CUSTOM-DRG,14248.12,Case rate,100% of GA Medicaid ,17810.15,31378.42,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27960.38,100,CUSTOM-DRG,22368.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,36572.83,102,MS-DRG,29258.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27960.38,100,CUSTOM-DRG,22368.3,Case rate,100% of GA Medicaid ,35855.72,100,MS-DRG,28684.58,Case rate,100% of Medicare MS-DRG,27960.38,100,CUSTOM-DRG,22368.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27960.38,100,CUSTOM-DRG,22368.3,Case rate,100% of GA Medicaid ,27960.38,36572.83,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18906,100,CUSTOM-DRG,15124.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24457.24,102,MS-DRG,19565.79,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,18906,100,CUSTOM-DRG,15124.8,Case rate,100% of GA Medicaid ,23977.69,100,MS-DRG,19182.15,Case rate,100% of Medicare MS-DRG,18906,100,CUSTOM-DRG,15124.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18906,100,CUSTOM-DRG,15124.8,Case rate,100% of GA Medicaid ,18906,24457.24,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14731.44,100,CUSTOM-DRG,11785.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20149.01,102,MS-DRG,16119.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14731.44,100,CUSTOM-DRG,11785.15,Case rate,100% of GA Medicaid ,19753.93,100,MS-DRG,15803.14,Case rate,100% of Medicare MS-DRG,14731.44,100,CUSTOM-DRG,11785.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14731.44,100,CUSTOM-DRG,11785.15,Case rate,100% of GA Medicaid ,14731.44,20149.01,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27796.39,100,CUSTOM-DRG,22237.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,49907.5,102,MS-DRG,39926,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27796.39,100,CUSTOM-DRG,22237.11,Case rate,100% of GA Medicaid ,48928.92,100,MS-DRG,39143.14,Case rate,100% of Medicare MS-DRG,27796.39,100,CUSTOM-DRG,22237.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27796.39,100,CUSTOM-DRG,22237.11,Case rate,100% of GA Medicaid ,27796.39,49907.5,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17342,100,CUSTOM-DRG,13873.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28391.97,102,MS-DRG,22713.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17342,100,CUSTOM-DRG,13873.6,Case rate,100% of GA Medicaid ,27835.26,100,MS-DRG,22268.21,Case rate,100% of Medicare MS-DRG,17342,100,CUSTOM-DRG,13873.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17342,100,CUSTOM-DRG,13873.6,Case rate,100% of GA Medicaid ,17342,28391.97,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11593.46,100,CUSTOM-DRG,9274.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19205.7,102,MS-DRG,15364.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11593.46,100,CUSTOM-DRG,9274.77,Case rate,100% of GA Medicaid ,18829.12,100,MS-DRG,15063.3,Case rate,100% of Medicare MS-DRG,11593.46,100,CUSTOM-DRG,9274.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11593.46,100,CUSTOM-DRG,9274.77,Case rate,100% of GA Medicaid ,11593.46,19205.7,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13970.77,100,CUSTOM-DRG,11176.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,34093.22,102,MS-DRG,27274.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13970.77,100,CUSTOM-DRG,11176.62,Case rate,100% of GA Medicaid ,33424.73,100,MS-DRG,26739.78,Case rate,100% of Medicare MS-DRG,13970.77,100,CUSTOM-DRG,11176.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13970.77,100,CUSTOM-DRG,11176.62,Case rate,100% of GA Medicaid ,13970.77,34093.22,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8948.01,100,CUSTOM-DRG,7158.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17837.53,102,MS-DRG,14270.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8948.01,100,CUSTOM-DRG,7158.41,Case rate,100% of GA Medicaid ,17487.77,100,MS-DRG,13990.22,Case rate,100% of Medicare MS-DRG,8948.01,100,CUSTOM-DRG,7158.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8948.01,100,CUSTOM-DRG,7158.41,Case rate,100% of GA Medicaid ,8948.01,17837.53,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7362.4,100,CUSTOM-DRG,5889.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13440.68,102,MS-DRG,10752.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7362.4,100,CUSTOM-DRG,5889.92,Case rate,100% of GA Medicaid ,13177.14,100,MS-DRG,10541.71,Case rate,100% of Medicare MS-DRG,7362.4,100,CUSTOM-DRG,5889.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7362.4,100,CUSTOM-DRG,5889.92,Case rate,100% of GA Medicaid ,7362.4,13440.68,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24281.68,100,CUSTOM-DRG,19425.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32310.96,102,MS-DRG,25848.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,24281.68,100,CUSTOM-DRG,19425.34,Case rate,100% of GA Medicaid ,31677.41,100,MS-DRG,25341.93,Case rate,100% of Medicare MS-DRG,24281.68,100,CUSTOM-DRG,19425.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24281.68,100,CUSTOM-DRG,19425.34,Case rate,100% of GA Medicaid ,24281.68,32310.96,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11210.64,100,CUSTOM-DRG,8968.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19044.2,102,MS-DRG,15235.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11210.64,100,CUSTOM-DRG,8968.51,Case rate,100% of GA Medicaid ,18670.78,100,MS-DRG,14936.62,Case rate,100% of Medicare MS-DRG,11210.64,100,CUSTOM-DRG,8968.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11210.64,100,CUSTOM-DRG,8968.51,Case rate,100% of GA Medicaid ,11210.64,19044.2,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7252.15,100,CUSTOM-DRG,5801.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14975.3,102,MS-DRG,11980.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7252.15,100,CUSTOM-DRG,5801.72,Case rate,100% of GA Medicaid ,14681.67,100,MS-DRG,11745.34,Case rate,100% of Medicare MS-DRG,7252.15,100,CUSTOM-DRG,5801.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7252.15,100,CUSTOM-DRG,5801.72,Case rate,100% of GA Medicaid ,7252.15,14975.3,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14901.53,100,CUSTOM-DRG,11921.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27956.33,102,MS-DRG,22365.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14901.53,100,CUSTOM-DRG,11921.22,Case rate,100% of GA Medicaid ,27408.17,100,MS-DRG,21926.54,Case rate,100% of Medicare MS-DRG,14901.53,100,CUSTOM-DRG,11921.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14901.53,100,CUSTOM-DRG,11921.22,Case rate,100% of GA Medicaid ,14901.53,27956.33,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10130.29,100,CUSTOM-DRG,8104.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13250.19,102,MS-DRG,10600.15,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10130.29,100,CUSTOM-DRG,8104.23,Case rate,100% of GA Medicaid ,12990.38,100,MS-DRG,10392.3,Case rate,100% of Medicare MS-DRG,10130.29,100,CUSTOM-DRG,8104.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10130.29,100,CUSTOM-DRG,8104.23,Case rate,100% of GA Medicaid ,10130.29,13250.19,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6339.12,100,CUSTOM-DRG,5071.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9532.67,102,MS-DRG,7626.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6339.12,100,CUSTOM-DRG,5071.3,Case rate,100% of GA Medicaid ,9345.75,100,MS-DRG,7476.6,Case rate,100% of Medicare MS-DRG,6339.12,100,CUSTOM-DRG,5071.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6339.12,100,CUSTOM-DRG,5071.3,Case rate,100% of GA Medicaid ,6339.12,9532.67,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16423.98,100,CUSTOM-DRG,13139.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,31889.41,102,MS-DRG,25511.53,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16423.98,100,CUSTOM-DRG,13139.18,Case rate,100% of GA Medicaid ,31264.13,100,MS-DRG,25011.3,Case rate,100% of Medicare MS-DRG,16423.98,100,CUSTOM-DRG,13139.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16423.98,100,CUSTOM-DRG,13139.18,Case rate,100% of GA Medicaid ,16423.98,31889.41,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16002.93,100,CUSTOM-DRG,12802.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18474.41,102,MS-DRG,14779.53,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16002.93,100,CUSTOM-DRG,12802.34,Case rate,100% of GA Medicaid ,18112.17,100,MS-DRG,14489.74,Case rate,100% of Medicare MS-DRG,16002.93,100,CUSTOM-DRG,12802.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16002.93,100,CUSTOM-DRG,12802.34,Case rate,100% of GA Medicaid ,16002.93,18474.41,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8010.05,100,CUSTOM-DRG,6408.04,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14408.84,102,MS-DRG,11527.07,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8010.05,100,CUSTOM-DRG,6408.04,Case rate,100% of GA Medicaid ,14126.31,100,MS-DRG,11301.05,Case rate,100% of Medicare MS-DRG,8010.05,100,CUSTOM-DRG,6408.04,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8010.05,100,CUSTOM-DRG,6408.04,Case rate,100% of GA Medicaid ,8010.05,14408.84,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,43423.14,100,CUSTOM-DRG,34738.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16104.14,102,MS-DRG,12883.31,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,43423.14,100,CUSTOM-DRG,34738.51,Case rate,100% of GA Medicaid ,15788.37,100,MS-DRG,12630.7,Case rate,100% of Medicare MS-DRG,43423.14,100,CUSTOM-DRG,34738.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,43423.14,100,CUSTOM-DRG,34738.51,Case rate,100% of GA Medicaid ,15788.37,43423.14,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4505.31,100,CUSTOM-DRG,3604.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8509.28,102,MS-DRG,6807.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4505.31,100,CUSTOM-DRG,3604.25,Case rate,100% of GA Medicaid ,8342.43,100,MS-DRG,6673.94,Case rate,100% of Medicare MS-DRG,4505.31,100,CUSTOM-DRG,3604.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4505.31,100,CUSTOM-DRG,3604.25,Case rate,100% of GA Medicaid ,4505.31,8509.28,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9444.97,100,CUSTOM-DRG,7555.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12203.37,102,MS-DRG,9762.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9444.97,100,CUSTOM-DRG,7555.98,Case rate,100% of GA Medicaid ,11964.09,100,MS-DRG,9571.27,Case rate,100% of Medicare MS-DRG,9444.97,100,CUSTOM-DRG,7555.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9444.97,100,CUSTOM-DRG,7555.98,Case rate,100% of GA Medicaid ,9444.97,12203.37,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7527.5,100,CUSTOM-DRG,6022,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9091.29,102,MS-DRG,7273.03,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7527.5,100,CUSTOM-DRG,6022,Case rate,100% of GA Medicaid ,8913.03,100,MS-DRG,7130.42,Case rate,100% of Medicare MS-DRG,7527.5,100,CUSTOM-DRG,6022,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7527.5,100,CUSTOM-DRG,6022,Case rate,100% of GA Medicaid ,7527.5,9091.29,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16184.09,100,CUSTOM-DRG,12947.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19826.85,102,MS-DRG,15861.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16184.09,100,CUSTOM-DRG,12947.27,Case rate,100% of GA Medicaid ,19438.09,100,MS-DRG,15550.47,Case rate,100% of Medicare MS-DRG,16184.09,100,CUSTOM-DRG,12947.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16184.09,100,CUSTOM-DRG,12947.27,Case rate,100% of GA Medicaid ,16184.09,19826.85,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8849.95,100,CUSTOM-DRG,7079.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11289.87,102,MS-DRG,9031.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8849.95,100,CUSTOM-DRG,7079.96,Case rate,100% of GA Medicaid ,11068.5,100,MS-DRG,8854.8,Case rate,100% of Medicare MS-DRG,8849.95,100,CUSTOM-DRG,7079.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8849.95,100,CUSTOM-DRG,7079.96,Case rate,100% of GA Medicaid ,8849.95,11289.87,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7259.35,100,CUSTOM-DRG,5807.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14310.27,102,MS-DRG,11448.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7259.35,100,CUSTOM-DRG,5807.48,Case rate,100% of GA Medicaid ,14029.68,100,MS-DRG,11223.74,Case rate,100% of Medicare MS-DRG,7259.35,100,CUSTOM-DRG,5807.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7259.35,100,CUSTOM-DRG,5807.48,Case rate,100% of GA Medicaid ,7259.35,14310.27,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7243.28,100,CUSTOM-DRG,5794.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9833.44,102,MS-DRG,7866.75,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7243.28,100,CUSTOM-DRG,5794.62,Case rate,100% of GA Medicaid ,9640.63,100,MS-DRG,7712.5,Case rate,100% of Medicare MS-DRG,7243.28,100,CUSTOM-DRG,5794.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7243.28,100,CUSTOM-DRG,5794.62,Case rate,100% of GA Medicaid ,7243.28,9833.44,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4706.42,100,CUSTOM-DRG,3765.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7946.8,102,MS-DRG,6357.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4706.42,100,CUSTOM-DRG,3765.14,Case rate,100% of GA Medicaid ,7790.98,100,MS-DRG,6232.78,Case rate,100% of Medicare MS-DRG,4706.42,100,CUSTOM-DRG,3765.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4706.42,100,CUSTOM-DRG,3765.14,Case rate,100% of GA Medicaid ,4706.42,7946.8,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12825.61,100,CUSTOM-DRG,10260.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23212.48,102,MS-DRG,18569.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12825.61,100,CUSTOM-DRG,10260.49,Case rate,100% of GA Medicaid ,22757.33,100,MS-DRG,18205.86,Case rate,100% of Medicare MS-DRG,12825.61,100,CUSTOM-DRG,10260.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12825.61,100,CUSTOM-DRG,10260.49,Case rate,100% of GA Medicaid ,12825.61,23212.48,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9366.85,100,CUSTOM-DRG,7493.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15501.22,102,MS-DRG,12400.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9366.85,100,CUSTOM-DRG,7493.48,Case rate,100% of GA Medicaid ,15197.27,100,MS-DRG,12157.82,Case rate,100% of Medicare MS-DRG,9366.85,100,CUSTOM-DRG,7493.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9366.85,100,CUSTOM-DRG,7493.48,Case rate,100% of GA Medicaid ,9366.85,15501.22,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8252.71,100,CUSTOM-DRG,6602.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12313.5,102,MS-DRG,9850.8,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8252.71,100,CUSTOM-DRG,6602.17,Case rate,100% of GA Medicaid ,12072.06,100,MS-DRG,9657.65,Case rate,100% of Medicare MS-DRG,8252.71,100,CUSTOM-DRG,6602.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8252.71,100,CUSTOM-DRG,6602.17,Case rate,100% of GA Medicaid ,8252.71,12313.5,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14879.92,100,CUSTOM-DRG,11903.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16588.62,102,MS-DRG,13270.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14879.92,100,CUSTOM-DRG,11903.94,Case rate,100% of GA Medicaid ,16263.35,100,MS-DRG,13010.68,Case rate,100% of Medicare MS-DRG,14879.92,100,CUSTOM-DRG,11903.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14879.92,100,CUSTOM-DRG,11903.94,Case rate,100% of GA Medicaid ,14879.92,16588.62,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8042.74,100,CUSTOM-DRG,6434.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8721.51,102,MS-DRG,6977.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8042.74,100,CUSTOM-DRG,6434.19,Case rate,100% of GA Medicaid ,8550.5,100,MS-DRG,6840.4,Case rate,100% of Medicare MS-DRG,8042.74,100,CUSTOM-DRG,6434.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8042.74,100,CUSTOM-DRG,6434.19,Case rate,100% of GA Medicaid ,8042.74,8721.51,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4544.09,100,CUSTOM-DRG,3635.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6580.32,102,MS-DRG,5264.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4544.09,100,CUSTOM-DRG,3635.27,Case rate,100% of GA Medicaid ,6451.29,100,MS-DRG,5161.03,Case rate,100% of Medicare MS-DRG,4544.09,100,CUSTOM-DRG,3635.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4544.09,100,CUSTOM-DRG,3635.27,Case rate,100% of GA Medicaid ,4544.09,6580.32,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6267.1,100,CUSTOM-DRG,5013.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11734.6,102,MS-DRG,9387.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6267.1,100,CUSTOM-DRG,5013.68,Case rate,100% of GA Medicaid ,11504.51,100,MS-DRG,9203.61,Case rate,100% of Medicare MS-DRG,6267.1,100,CUSTOM-DRG,5013.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6267.1,100,CUSTOM-DRG,5013.68,Case rate,100% of GA Medicaid ,6267.1,11734.6,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4386.75,100,CUSTOM-DRG,3509.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7774.92,102,MS-DRG,6219.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4386.75,100,CUSTOM-DRG,3509.4,Case rate,100% of GA Medicaid ,7622.47,100,MS-DRG,6097.98,Case rate,100% of Medicare MS-DRG,4386.75,100,CUSTOM-DRG,3509.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4386.75,100,CUSTOM-DRG,3509.4,Case rate,100% of GA Medicaid ,4386.75,7774.92,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4210.01,100,CUSTOM-DRG,3368.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7304.25,102,MS-DRG,5843.4,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4210.01,100,CUSTOM-DRG,3368.01,Case rate,100% of GA Medicaid ,7161.03,100,MS-DRG,5728.82,Case rate,100% of Medicare MS-DRG,4210.01,100,CUSTOM-DRG,3368.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4210.01,100,CUSTOM-DRG,3368.01,Case rate,100% of GA Medicaid ,4210.01,7304.25,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10494.28,100,CUSTOM-DRG,8395.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14820.44,102,MS-DRG,11856.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10494.28,100,CUSTOM-DRG,8395.42,Case rate,100% of GA Medicaid ,14529.84,100,MS-DRG,11623.87,Case rate,100% of Medicare MS-DRG,10494.28,100,CUSTOM-DRG,8395.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10494.28,100,CUSTOM-DRG,8395.42,Case rate,100% of GA Medicaid ,10494.28,14820.44,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6682.61,100,CUSTOM-DRG,5346.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9017.07,102,MS-DRG,7213.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6682.61,100,CUSTOM-DRG,5346.09,Case rate,100% of GA Medicaid ,8840.26,100,MS-DRG,7072.21,Case rate,100% of Medicare MS-DRG,6682.61,100,CUSTOM-DRG,5346.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6682.61,100,CUSTOM-DRG,5346.09,Case rate,100% of GA Medicaid ,6682.61,9017.07,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3770.12,100,CUSTOM-DRG,3016.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7202.03,102,MS-DRG,5761.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3770.12,100,CUSTOM-DRG,3016.1,Case rate,100% of GA Medicaid ,7060.81,100,MS-DRG,5648.65,Case rate,100% of Medicare MS-DRG,3770.12,100,CUSTOM-DRG,3016.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3770.12,100,CUSTOM-DRG,3016.1,Case rate,100% of GA Medicaid ,3770.12,7202.03,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8278.2,100,CUSTOM-DRG,6622.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12530.5,102,MS-DRG,10024.4,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8278.2,100,CUSTOM-DRG,6622.56,Case rate,100% of GA Medicaid ,12284.8,100,MS-DRG,9827.84,Case rate,100% of Medicare MS-DRG,8278.2,100,CUSTOM-DRG,6622.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8278.2,100,CUSTOM-DRG,6622.56,Case rate,100% of GA Medicaid ,8278.2,12530.5,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5255.45,100,CUSTOM-DRG,4204.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8785.3,102,MS-DRG,7028.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5255.45,100,CUSTOM-DRG,4204.36,Case rate,100% of GA Medicaid ,8613.04,100,MS-DRG,6890.43,Case rate,100% of Medicare MS-DRG,5255.45,100,CUSTOM-DRG,4204.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5255.45,100,CUSTOM-DRG,4204.36,Case rate,100% of GA Medicaid ,5255.45,8785.3,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5132.46,100,CUSTOM-DRG,4105.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15849.87,102,MS-DRG,12679.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5132.46,100,CUSTOM-DRG,4105.97,Case rate,100% of GA Medicaid ,15539.09,100,MS-DRG,12431.27,Case rate,100% of Medicare MS-DRG,5132.46,100,CUSTOM-DRG,4105.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5132.46,100,CUSTOM-DRG,4105.97,Case rate,100% of GA Medicaid ,5132.46,15849.87,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3062.63,100,CUSTOM-DRG,2450.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8110.19,102,MS-DRG,6488.15,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3062.63,100,CUSTOM-DRG,2450.1,Case rate,100% of GA Medicaid ,7951.17,100,MS-DRG,6360.94,Case rate,100% of Medicare MS-DRG,3062.63,100,CUSTOM-DRG,2450.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3062.63,100,CUSTOM-DRG,2450.1,Case rate,100% of GA Medicaid ,3062.63,8110.19,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6033.85,100,CUSTOM-DRG,4827.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12513.11,102,MS-DRG,10010.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6033.85,100,CUSTOM-DRG,4827.08,Case rate,100% of GA Medicaid ,12267.75,100,MS-DRG,9814.2,Case rate,100% of Medicare MS-DRG,6033.85,100,CUSTOM-DRG,4827.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6033.85,100,CUSTOM-DRG,4827.08,Case rate,100% of GA Medicaid ,6033.85,12513.11,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5506.42,100,CUSTOM-DRG,4405.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8724.75,102,MS-DRG,6979.8,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5506.42,100,CUSTOM-DRG,4405.14,Case rate,100% of GA Medicaid ,8553.68,100,MS-DRG,6842.94,Case rate,100% of Medicare MS-DRG,5506.42,100,CUSTOM-DRG,4405.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5506.42,100,CUSTOM-DRG,4405.14,Case rate,100% of GA Medicaid ,5506.42,8724.75,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3689.79,100,CUSTOM-DRG,2951.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6927.31,102,MS-DRG,5541.85,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3689.79,100,CUSTOM-DRG,2951.83,Case rate,100% of GA Medicaid ,6791.48,100,MS-DRG,5433.18,Case rate,100% of Medicare MS-DRG,3689.79,100,CUSTOM-DRG,2951.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3689.79,100,CUSTOM-DRG,2951.83,Case rate,100% of GA Medicaid ,3689.79,6927.31,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4360.71,100,CUSTOM-DRG,3488.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18292.21,102,MS-DRG,14633.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4360.71,100,CUSTOM-DRG,3488.57,Case rate,100% of GA Medicaid ,17933.54,100,MS-DRG,14346.83,Case rate,100% of Medicare MS-DRG,4360.71,100,CUSTOM-DRG,3488.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4360.71,100,CUSTOM-DRG,3488.57,Case rate,100% of GA Medicaid ,4360.71,18292.21,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2912.49,100,CUSTOM-DRG,2329.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8025.56,102,MS-DRG,6420.45,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2912.49,100,CUSTOM-DRG,2329.99,Case rate,100% of GA Medicaid ,7868.2,100,MS-DRG,6294.56,Case rate,100% of Medicare MS-DRG,2912.49,100,CUSTOM-DRG,2329.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2912.49,100,CUSTOM-DRG,2329.99,Case rate,100% of GA Medicaid ,2912.49,8025.56,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9915.89,100,CUSTOM-DRG,7932.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18868.63,102,MS-DRG,15094.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9915.89,100,CUSTOM-DRG,7932.71,Case rate,100% of GA Medicaid ,18498.66,100,MS-DRG,14798.93,Case rate,100% of Medicare MS-DRG,9915.89,100,CUSTOM-DRG,7932.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9915.89,100,CUSTOM-DRG,7932.71,Case rate,100% of GA Medicaid ,9915.89,18868.63,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11233.55,102,MS-DRG,8986.84,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,11013.28,100,MS-DRG,8810.62,Case rate,100% of Medicare MS-DRG,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,6600.06,11233.55,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4868.75,100,CUSTOM-DRG,3895,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8091.97,102,MS-DRG,6473.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4868.75,100,CUSTOM-DRG,3895,Case rate,100% of GA Medicaid ,7933.3,100,MS-DRG,6346.64,Case rate,100% of Medicare MS-DRG,4868.75,100,CUSTOM-DRG,3895,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4868.75,100,CUSTOM-DRG,3895,Case rate,100% of GA Medicaid ,4868.75,8091.97,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8600.64,100,CUSTOM-DRG,6880.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18823.08,102,MS-DRG,15058.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8600.64,100,CUSTOM-DRG,6880.51,Case rate,100% of GA Medicaid ,18454,100,MS-DRG,14763.2,Case rate,100% of Medicare MS-DRG,8600.64,100,CUSTOM-DRG,6880.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8600.64,100,CUSTOM-DRG,6880.51,Case rate,100% of GA Medicaid ,8600.64,18823.08,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4798.94,100,CUSTOM-DRG,3839.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10908.06,102,MS-DRG,8726.45,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4798.94,100,CUSTOM-DRG,3839.15,Case rate,100% of GA Medicaid ,10694.18,100,MS-DRG,8555.34,Case rate,100% of Medicare MS-DRG,4798.94,100,CUSTOM-DRG,3839.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4798.94,100,CUSTOM-DRG,3839.15,Case rate,100% of GA Medicaid ,4798.94,10908.06,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3711.39,100,CUSTOM-DRG,2969.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7873.87,102,MS-DRG,6299.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3711.39,100,CUSTOM-DRG,2969.11,Case rate,100% of GA Medicaid ,7719.48,100,MS-DRG,6175.58,Case rate,100% of Medicare MS-DRG,3711.39,100,CUSTOM-DRG,2969.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3711.39,100,CUSTOM-DRG,2969.11,Case rate,100% of GA Medicaid ,3711.39,7873.87,
CONCUSSION WITH MCC,88,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7429.99,100,CUSTOM-DRG,5943.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12702.76,102,MS-DRG,10162.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7429.99,100,CUSTOM-DRG,5943.99,Case rate,100% of GA Medicaid ,12453.69,100,MS-DRG,9962.95,Case rate,100% of Medicare MS-DRG,7429.99,100,CUSTOM-DRG,5943.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7429.99,100,CUSTOM-DRG,5943.99,Case rate,100% of GA Medicaid ,7429.99,12702.76,
CONCUSSION WITH CC,89,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5953.52,100,CUSTOM-DRG,4762.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9590.61,102,MS-DRG,7672.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5953.52,100,CUSTOM-DRG,4762.82,Case rate,100% of GA Medicaid ,9402.56,100,MS-DRG,7522.05,Case rate,100% of Medicare MS-DRG,5953.52,100,CUSTOM-DRG,4762.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5953.52,100,CUSTOM-DRG,4762.82,Case rate,100% of GA Medicaid ,5953.52,9590.61,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3547.4,100,CUSTOM-DRG,2837.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8190.28,102,MS-DRG,6552.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3547.4,100,CUSTOM-DRG,2837.92,Case rate,100% of GA Medicaid ,8029.69,100,MS-DRG,6423.75,Case rate,100% of Medicare MS-DRG,3547.4,100,CUSTOM-DRG,2837.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3547.4,100,CUSTOM-DRG,2837.92,Case rate,100% of GA Medicaid ,3547.4,8190.28,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12770.21,100,CUSTOM-DRG,10216.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14817.95,102,MS-DRG,11854.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12770.21,100,CUSTOM-DRG,10216.17,Case rate,100% of GA Medicaid ,14527.4,100,MS-DRG,11621.92,Case rate,100% of Medicare MS-DRG,12770.21,100,CUSTOM-DRG,10216.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12770.21,100,CUSTOM-DRG,10216.17,Case rate,100% of GA Medicaid ,12770.21,14817.95,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6355.74,100,CUSTOM-DRG,5084.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8784.66,102,MS-DRG,7027.73,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6355.74,100,CUSTOM-DRG,5084.59,Case rate,100% of GA Medicaid ,8612.41,100,MS-DRG,6889.93,Case rate,100% of Medicare MS-DRG,6355.74,100,CUSTOM-DRG,5084.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6355.74,100,CUSTOM-DRG,5084.59,Case rate,100% of GA Medicaid ,6355.74,8784.66,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4649.91,100,CUSTOM-DRG,3719.93,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7146.05,102,MS-DRG,5716.84,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4649.91,100,CUSTOM-DRG,3719.93,Case rate,100% of GA Medicaid ,7005.93,100,MS-DRG,5604.74,Case rate,100% of Medicare MS-DRG,4649.91,100,CUSTOM-DRG,3719.93,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4649.91,100,CUSTOM-DRG,3719.93,Case rate,100% of GA Medicaid ,4649.91,7146.05,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25496.09,100,CUSTOM-DRG,20396.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30002.79,102,MS-DRG,24002.23,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,25496.09,100,CUSTOM-DRG,20396.87,Case rate,100% of GA Medicaid ,29414.5,100,MS-DRG,23531.6,Case rate,100% of Medicare MS-DRG,25496.09,100,CUSTOM-DRG,20396.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25496.09,100,CUSTOM-DRG,20396.87,Case rate,100% of GA Medicaid ,25496.09,30002.79,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20403.52,100,CUSTOM-DRG,16322.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19745.69,102,MS-DRG,15796.55,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,20403.52,100,CUSTOM-DRG,16322.82,Case rate,100% of GA Medicaid ,19358.52,100,MS-DRG,15486.82,Case rate,100% of Medicare MS-DRG,20403.52,100,CUSTOM-DRG,16322.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20403.52,100,CUSTOM-DRG,16322.82,Case rate,100% of GA Medicaid ,19358.52,20403.52,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18052.04,102,MS-DRG,14441.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,17698.08,100,MS-DRG,14158.46,Case rate,100% of Medicare MS-DRG,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,10852.74,18052.04,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19392.43,100,CUSTOM-DRG,15513.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30120.4,102,MS-DRG,24096.32,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19392.43,100,CUSTOM-DRG,15513.94,Case rate,100% of GA Medicaid ,29529.8,100,MS-DRG,23623.84,Case rate,100% of Medicare MS-DRG,19392.43,100,CUSTOM-DRG,15513.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19392.43,100,CUSTOM-DRG,15513.94,Case rate,100% of GA Medicaid ,19392.43,30120.4,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11214.51,100,CUSTOM-DRG,8971.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17843.34,102,MS-DRG,14274.67,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11214.51,100,CUSTOM-DRG,8971.61,Case rate,100% of GA Medicaid ,17493.47,100,MS-DRG,13994.78,Case rate,100% of Medicare MS-DRG,11214.51,100,CUSTOM-DRG,8971.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11214.51,100,CUSTOM-DRG,8971.61,Case rate,100% of GA Medicaid ,11214.51,17843.34,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5458.22,100,CUSTOM-DRG,4366.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10933.76,102,MS-DRG,8747.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5458.22,100,CUSTOM-DRG,4366.58,Case rate,100% of GA Medicaid ,10719.37,100,MS-DRG,8575.5,Case rate,100% of Medicare MS-DRG,5458.22,100,CUSTOM-DRG,4366.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5458.22,100,CUSTOM-DRG,4366.58,Case rate,100% of GA Medicaid ,5458.22,10933.76,
SEIZURES WITH MCC,100,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9408.4,100,CUSTOM-DRG,7526.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16418.85,102,MS-DRG,13135.08,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9408.4,100,CUSTOM-DRG,7526.72,Case rate,100% of GA Medicaid ,16096.91,100,MS-DRG,12877.53,Case rate,100% of Medicare MS-DRG,9408.4,100,CUSTOM-DRG,7526.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9408.4,100,CUSTOM-DRG,7526.72,Case rate,100% of GA Medicaid ,9408.4,16418.85,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4242.15,100,CUSTOM-DRG,3393.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8026.23,102,MS-DRG,6420.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4242.15,100,CUSTOM-DRG,3393.72,Case rate,100% of GA Medicaid ,7868.85,100,MS-DRG,6295.08,Case rate,100% of Medicare MS-DRG,4242.15,100,CUSTOM-DRG,3393.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4242.15,100,CUSTOM-DRG,3393.72,Case rate,100% of GA Medicaid ,4242.15,8026.23,
HEADACHES WITH MCC,102,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5071.52,100,CUSTOM-DRG,4057.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9992.93,102,MS-DRG,7994.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5071.52,100,CUSTOM-DRG,4057.22,Case rate,100% of GA Medicaid ,9796.99,100,MS-DRG,7837.59,Case rate,100% of Medicare MS-DRG,5071.52,100,CUSTOM-DRG,4057.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5071.52,100,CUSTOM-DRG,4057.22,Case rate,100% of GA Medicaid ,5071.52,9992.93,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3906.41,100,CUSTOM-DRG,3125.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7588.75,102,MS-DRG,6071,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3906.41,100,CUSTOM-DRG,3125.13,Case rate,100% of GA Medicaid ,7439.95,100,MS-DRG,5951.96,Case rate,100% of Medicare MS-DRG,3906.41,100,CUSTOM-DRG,3125.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3906.41,100,CUSTOM-DRG,3125.13,Case rate,100% of GA Medicaid ,3906.41,7588.75,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10039.99,100,CUSTOM-DRG,8031.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20765.18,102,MS-DRG,16612.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10039.99,100,CUSTOM-DRG,8031.99,Case rate,100% of GA Medicaid ,20358.02,100,MS-DRG,16286.42,Case rate,100% of Medicare MS-DRG,10039.99,100,CUSTOM-DRG,8031.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10039.99,100,CUSTOM-DRG,8031.99,Case rate,100% of GA Medicaid ,10039.99,20765.18,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6461.56,100,CUSTOM-DRG,5169.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10201.63,102,MS-DRG,8161.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6461.56,100,CUSTOM-DRG,5169.25,Case rate,100% of GA Medicaid ,10001.6,100,MS-DRG,8001.28,Case rate,100% of Medicare MS-DRG,6461.56,100,CUSTOM-DRG,5169.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6461.56,100,CUSTOM-DRG,5169.25,Case rate,100% of GA Medicaid ,6461.56,10201.63,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6967.38,100,CUSTOM-DRG,5573.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12956.19,102,MS-DRG,10364.95,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6967.38,100,CUSTOM-DRG,5573.9,Case rate,100% of GA Medicaid ,12702.15,100,MS-DRG,10161.72,Case rate,100% of Medicare MS-DRG,6967.38,100,CUSTOM-DRG,5573.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6967.38,100,CUSTOM-DRG,5573.9,Case rate,100% of GA Medicaid ,6967.38,12956.19,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7116.97,100,CUSTOM-DRG,5693.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15162.48,102,MS-DRG,12129.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7116.97,100,CUSTOM-DRG,5693.58,Case rate,100% of GA Medicaid ,14865.18,100,MS-DRG,11892.14,Case rate,100% of Medicare MS-DRG,7116.97,100,CUSTOM-DRG,5693.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7116.97,100,CUSTOM-DRG,5693.58,Case rate,100% of GA Medicaid ,7116.97,15162.48,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5215.01,100,CUSTOM-DRG,4172.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9925.02,102,MS-DRG,7940.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5215.01,100,CUSTOM-DRG,4172.01,Case rate,100% of GA Medicaid ,9730.41,100,MS-DRG,7784.33,Case rate,100% of Medicare MS-DRG,5215.01,100,CUSTOM-DRG,4172.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5215.01,100,CUSTOM-DRG,4172.01,Case rate,100% of GA Medicaid ,5215.01,9925.02,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3471.5,100,CUSTOM-DRG,2777.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10610.74,102,MS-DRG,8488.59,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3471.5,100,CUSTOM-DRG,2777.2,Case rate,100% of GA Medicaid ,10402.69,100,MS-DRG,8322.15,Case rate,100% of Medicare MS-DRG,3471.5,100,CUSTOM-DRG,2777.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3471.5,100,CUSTOM-DRG,2777.2,Case rate,100% of GA Medicaid ,3471.5,10610.74,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2959.59,100,CUSTOM-DRG,2367.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6951.4,102,MS-DRG,5561.12,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2959.59,100,CUSTOM-DRG,2367.67,Case rate,100% of GA Medicaid ,6815.1,100,MS-DRG,5452.08,Case rate,100% of Medicare MS-DRG,2959.59,100,CUSTOM-DRG,2367.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2959.59,100,CUSTOM-DRG,2367.67,Case rate,100% of GA Medicaid ,2959.59,6951.4,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4594.5,100,CUSTOM-DRG,3675.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7338.75,102,MS-DRG,5871,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4594.5,100,CUSTOM-DRG,3675.6,Case rate,100% of GA Medicaid ,7194.85,100,MS-DRG,5755.88,Case rate,100% of Medicare MS-DRG,4594.5,100,CUSTOM-DRG,3675.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4594.5,100,CUSTOM-DRG,3675.6,Case rate,100% of GA Medicaid ,4594.5,7338.75,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4796.17,100,CUSTOM-DRG,3836.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10947.83,102,MS-DRG,8758.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4796.17,100,CUSTOM-DRG,3836.94,Case rate,100% of GA Medicaid ,10733.17,100,MS-DRG,8586.54,Case rate,100% of Medicare MS-DRG,4796.17,100,CUSTOM-DRG,3836.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4796.17,100,CUSTOM-DRG,3836.94,Case rate,100% of GA Medicaid ,4796.17,10947.83,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2990.61,100,CUSTOM-DRG,2392.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7296.44,102,MS-DRG,5837.15,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2990.61,100,CUSTOM-DRG,2392.49,Case rate,100% of GA Medicaid ,7153.37,100,MS-DRG,5722.7,Case rate,100% of Medicare MS-DRG,2990.61,100,CUSTOM-DRG,2392.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2990.61,100,CUSTOM-DRG,2392.49,Case rate,100% of GA Medicaid ,2990.61,7296.44,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11259.94,100,CUSTOM-DRG,9007.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21964.4,102,MS-DRG,17571.52,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11259.94,100,CUSTOM-DRG,9007.95,Case rate,100% of GA Medicaid ,21533.73,100,MS-DRG,17226.98,Case rate,100% of Medicare MS-DRG,11259.94,100,CUSTOM-DRG,9007.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11259.94,100,CUSTOM-DRG,9007.95,Case rate,100% of GA Medicaid ,11259.94,21964.4,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5738.01,100,CUSTOM-DRG,4590.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8903.13,102,MS-DRG,7122.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5738.01,100,CUSTOM-DRG,4590.41,Case rate,100% of GA Medicaid ,8728.56,100,MS-DRG,6982.85,Case rate,100% of Medicare MS-DRG,5738.01,100,CUSTOM-DRG,4590.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5738.01,100,CUSTOM-DRG,4590.41,Case rate,100% of GA Medicaid ,5738.01,8903.13,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5127.47,100,CUSTOM-DRG,4101.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12461.76,102,MS-DRG,9969.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5127.47,100,CUSTOM-DRG,4101.98,Case rate,100% of GA Medicaid ,12217.41,100,MS-DRG,9773.93,Case rate,100% of Medicare MS-DRG,5127.47,100,CUSTOM-DRG,4101.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5127.47,100,CUSTOM-DRG,4101.98,Case rate,100% of GA Medicaid ,5127.47,12461.76,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3790.62,100,CUSTOM-DRG,3032.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7740.42,102,MS-DRG,6192.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3790.62,100,CUSTOM-DRG,3032.5,Case rate,100% of GA Medicaid ,7588.65,100,MS-DRG,6070.92,Case rate,100% of Medicare MS-DRG,3790.62,100,CUSTOM-DRG,3032.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3790.62,100,CUSTOM-DRG,3032.5,Case rate,100% of GA Medicaid ,3790.62,7740.42,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5701.44,100,CUSTOM-DRG,4561.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9836.69,102,MS-DRG,7869.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5701.44,100,CUSTOM-DRG,4561.15,Case rate,100% of GA Medicaid ,9643.81,100,MS-DRG,7715.05,Case rate,100% of Medicare MS-DRG,5701.44,100,CUSTOM-DRG,4561.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5701.44,100,CUSTOM-DRG,4561.15,Case rate,100% of GA Medicaid ,5701.44,9836.69,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3664.86,100,CUSTOM-DRG,2931.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,31289.8,102,MS-DRG,25031.84,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3664.86,100,CUSTOM-DRG,2931.89,Case rate,100% of GA Medicaid ,30676.27,100,MS-DRG,24541.02,Case rate,100% of Medicare MS-DRG,3664.86,100,CUSTOM-DRG,2931.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3664.86,100,CUSTOM-DRG,2931.89,Case rate,100% of GA Medicaid ,3664.86,31289.8,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3077.59,100,CUSTOM-DRG,2462.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17157.59,102,MS-DRG,13726.07,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3077.59,100,CUSTOM-DRG,2462.07,Case rate,100% of GA Medicaid ,16821.17,100,MS-DRG,13456.94,Case rate,100% of Medicare MS-DRG,3077.59,100,CUSTOM-DRG,2462.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3077.59,100,CUSTOM-DRG,2462.07,Case rate,100% of GA Medicaid ,3077.59,17157.59,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7362.95,100,CUSTOM-DRG,5890.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12795.52,102,MS-DRG,10236.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7362.95,100,CUSTOM-DRG,5890.36,Case rate,100% of GA Medicaid ,12544.63,100,MS-DRG,10035.7,Case rate,100% of Medicare MS-DRG,7362.95,100,CUSTOM-DRG,5890.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7362.95,100,CUSTOM-DRG,5890.36,Case rate,100% of GA Medicaid ,7362.95,12795.52,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12523.11,100,CUSTOM-DRG,10018.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27542.24,102,MS-DRG,22033.79,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12523.11,100,CUSTOM-DRG,10018.49,Case rate,100% of GA Medicaid ,27002.2,100,MS-DRG,21601.76,Case rate,100% of Medicare MS-DRG,12523.11,100,CUSTOM-DRG,10018.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12523.11,100,CUSTOM-DRG,10018.49,Case rate,100% of GA Medicaid ,12523.11,27542.24,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3519.7,100,CUSTOM-DRG,2815.76,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14331.82,102,MS-DRG,11465.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3519.7,100,CUSTOM-DRG,2815.76,Case rate,100% of GA Medicaid ,14050.8,100,MS-DRG,11240.64,Case rate,100% of Medicare MS-DRG,3519.7,100,CUSTOM-DRG,2815.76,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3519.7,100,CUSTOM-DRG,2815.76,Case rate,100% of GA Medicaid ,3519.7,14331.82,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3885.91,100,CUSTOM-DRG,3108.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10113.02,102,MS-DRG,8090.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3885.91,100,CUSTOM-DRG,3108.73,Case rate,100% of GA Medicaid ,9914.73,100,MS-DRG,7931.78,Case rate,100% of Medicare MS-DRG,3885.91,100,CUSTOM-DRG,3108.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3885.91,100,CUSTOM-DRG,3108.73,Case rate,100% of GA Medicaid ,3885.91,10113.02,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7467.11,100,CUSTOM-DRG,5973.69,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17483.07,102,MS-DRG,13986.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7467.11,100,CUSTOM-DRG,5973.69,Case rate,100% of GA Medicaid ,17140.26,100,MS-DRG,13712.21,Case rate,100% of Medicare MS-DRG,7467.11,100,CUSTOM-DRG,5973.69,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7467.11,100,CUSTOM-DRG,5973.69,Case rate,100% of GA Medicaid ,7467.11,17483.07,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5579,100,CUSTOM-DRG,4463.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10234.76,102,MS-DRG,8187.81,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5579,100,CUSTOM-DRG,4463.2,Case rate,100% of GA Medicaid ,10034.08,100,MS-DRG,8027.26,Case rate,100% of Medicare MS-DRG,5579,100,CUSTOM-DRG,4463.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5579,100,CUSTOM-DRG,4463.2,Case rate,100% of GA Medicaid ,5579,10234.76,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4221.65,100,CUSTOM-DRG,3377.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7896.67,102,MS-DRG,6317.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4221.65,100,CUSTOM-DRG,3377.32,Case rate,100% of GA Medicaid ,7741.83,100,MS-DRG,6193.46,Case rate,100% of Medicare MS-DRG,4221.65,100,CUSTOM-DRG,3377.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4221.65,100,CUSTOM-DRG,3377.32,Case rate,100% of GA Medicaid ,4221.65,7896.67,
DYSEQUILIBRIUM,149,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3721.92,100,CUSTOM-DRG,2977.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6952.71,102,MS-DRG,5562.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3721.92,100,CUSTOM-DRG,2977.54,Case rate,100% of GA Medicaid ,6816.38,100,MS-DRG,5453.1,Case rate,100% of Medicare MS-DRG,3721.92,100,CUSTOM-DRG,2977.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3721.92,100,CUSTOM-DRG,2977.54,Case rate,100% of GA Medicaid ,3721.92,6952.71,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4618.33,100,CUSTOM-DRG,3694.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10886.54,102,MS-DRG,8709.23,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4618.33,100,CUSTOM-DRG,3694.66,Case rate,100% of GA Medicaid ,10673.08,100,MS-DRG,8538.46,Case rate,100% of Medicare MS-DRG,4618.33,100,CUSTOM-DRG,3694.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4618.33,100,CUSTOM-DRG,3694.66,Case rate,100% of GA Medicaid ,4618.33,10886.54,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2827.17,100,CUSTOM-DRG,2261.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7121.97,102,MS-DRG,5697.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2827.17,100,CUSTOM-DRG,2261.74,Case rate,100% of GA Medicaid ,6982.32,100,MS-DRG,5585.86,Case rate,100% of Medicare MS-DRG,2827.17,100,CUSTOM-DRG,2261.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2827.17,100,CUSTOM-DRG,2261.74,Case rate,100% of GA Medicaid ,2827.17,7121.97,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4184.53,100,CUSTOM-DRG,3347.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9840.54,102,MS-DRG,7872.43,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4184.53,100,CUSTOM-DRG,3347.62,Case rate,100% of GA Medicaid ,9647.59,100,MS-DRG,7718.07,Case rate,100% of Medicare MS-DRG,4184.53,100,CUSTOM-DRG,3347.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4184.53,100,CUSTOM-DRG,3347.62,Case rate,100% of GA Medicaid ,4184.53,9840.54,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3567.9,100,CUSTOM-DRG,2854.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6888.24,102,MS-DRG,5510.59,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3567.9,100,CUSTOM-DRG,2854.32,Case rate,100% of GA Medicaid ,6753.18,100,MS-DRG,5402.54,Case rate,100% of Medicare MS-DRG,3567.9,100,CUSTOM-DRG,2854.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3567.9,100,CUSTOM-DRG,2854.32,Case rate,100% of GA Medicaid ,3567.9,6888.24,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5964.6,100,CUSTOM-DRG,4771.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12739.2,102,MS-DRG,10191.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5964.6,100,CUSTOM-DRG,4771.68,Case rate,100% of GA Medicaid ,12489.41,100,MS-DRG,9991.53,Case rate,100% of Medicare MS-DRG,5964.6,100,CUSTOM-DRG,4771.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5964.6,100,CUSTOM-DRG,4771.68,Case rate,100% of GA Medicaid ,5964.6,12739.2,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3772.89,100,CUSTOM-DRG,3018.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8267.09,102,MS-DRG,6613.67,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3772.89,100,CUSTOM-DRG,3018.31,Case rate,100% of GA Medicaid ,8104.99,100,MS-DRG,6483.99,Case rate,100% of Medicare MS-DRG,3772.89,100,CUSTOM-DRG,3018.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3772.89,100,CUSTOM-DRG,3018.31,Case rate,100% of GA Medicaid ,3772.89,8267.09,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2991.72,100,CUSTOM-DRG,2393.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6372,102,MS-DRG,5097.6,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2991.72,100,CUSTOM-DRG,2393.38,Case rate,100% of GA Medicaid ,6247.06,100,MS-DRG,4997.65,Case rate,100% of Medicare MS-DRG,2991.72,100,CUSTOM-DRG,2393.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2991.72,100,CUSTOM-DRG,2393.38,Case rate,100% of GA Medicaid ,2991.72,6372,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5789.53,100,CUSTOM-DRG,4631.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14137.18,102,MS-DRG,11309.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5789.53,100,CUSTOM-DRG,4631.62,Case rate,100% of GA Medicaid ,13859.98,100,MS-DRG,11087.98,Case rate,100% of Medicare MS-DRG,5789.53,100,CUSTOM-DRG,4631.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5789.53,100,CUSTOM-DRG,4631.62,Case rate,100% of GA Medicaid ,5789.53,14137.18,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5124.7,100,CUSTOM-DRG,4099.76,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8214.37,102,MS-DRG,6571.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5124.7,100,CUSTOM-DRG,4099.76,Case rate,100% of GA Medicaid ,8053.3,100,MS-DRG,6442.64,Case rate,100% of Medicare MS-DRG,5124.7,100,CUSTOM-DRG,4099.76,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5124.7,100,CUSTOM-DRG,4099.76,Case rate,100% of GA Medicaid ,5124.7,8214.37,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6500.24,102,MS-DRG,5200.19,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,6372.78,100,MS-DRG,5098.22,Case rate,100% of Medicare MS-DRG,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,4001.7,6500.24,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,31534.38,100,CUSTOM-DRG,25227.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,39037.52,102,MS-DRG,31230.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,31534.38,100,CUSTOM-DRG,25227.5,Case rate,100% of GA Medicaid ,38272.08,100,MS-DRG,30617.66,Case rate,100% of Medicare MS-DRG,31534.38,100,CUSTOM-DRG,25227.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,31534.38,100,CUSTOM-DRG,25227.5,Case rate,100% of GA Medicaid ,31534.38,39037.52,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14625.63,100,CUSTOM-DRG,11700.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21122.12,102,MS-DRG,16897.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14625.63,100,CUSTOM-DRG,11700.5,Case rate,100% of GA Medicaid ,20707.96,100,MS-DRG,16566.37,Case rate,100% of Medicare MS-DRG,14625.63,100,CUSTOM-DRG,11700.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14625.63,100,CUSTOM-DRG,11700.5,Case rate,100% of GA Medicaid ,14625.63,21122.12,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9976.27,100,CUSTOM-DRG,7981.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15540.13,102,MS-DRG,12432.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9976.27,100,CUSTOM-DRG,7981.02,Case rate,100% of GA Medicaid ,15235.42,100,MS-DRG,12188.34,Case rate,100% of Medicare MS-DRG,9976.27,100,CUSTOM-DRG,7981.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9976.27,100,CUSTOM-DRG,7981.02,Case rate,100% of GA Medicaid ,9976.27,15540.13,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23152.58,100,CUSTOM-DRG,18522.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,33606.26,102,MS-DRG,26885.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,23152.58,100,CUSTOM-DRG,18522.06,Case rate,100% of GA Medicaid ,32947.31,100,MS-DRG,26357.85,Case rate,100% of Medicare MS-DRG,23152.58,100,CUSTOM-DRG,18522.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23152.58,100,CUSTOM-DRG,18522.06,Case rate,100% of GA Medicaid ,23152.58,33606.26,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10687.64,100,CUSTOM-DRG,8550.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15071.38,102,MS-DRG,12057.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10687.64,100,CUSTOM-DRG,8550.11,Case rate,100% of GA Medicaid ,14775.86,100,MS-DRG,11820.69,Case rate,100% of Medicare MS-DRG,10687.64,100,CUSTOM-DRG,8550.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10687.64,100,CUSTOM-DRG,8550.11,Case rate,100% of GA Medicaid ,10687.64,15071.38,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7393.42,100,CUSTOM-DRG,5914.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11227.75,102,MS-DRG,8982.2,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7393.42,100,CUSTOM-DRG,5914.74,Case rate,100% of GA Medicaid ,11007.6,100,MS-DRG,8806.08,Case rate,100% of Medicare MS-DRG,7393.42,100,CUSTOM-DRG,5914.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7393.42,100,CUSTOM-DRG,5914.74,Case rate,100% of GA Medicaid ,7393.42,11227.75,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6515.85,100,CUSTOM-DRG,5212.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25466.81,102,MS-DRG,20373.45,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6515.85,100,CUSTOM-DRG,5212.68,Case rate,100% of GA Medicaid ,24967.46,100,MS-DRG,19973.97,Case rate,100% of Medicare MS-DRG,6515.85,100,CUSTOM-DRG,5212.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6515.85,100,CUSTOM-DRG,5212.68,Case rate,100% of GA Medicaid ,6515.85,25466.81,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8775.71,100,CUSTOM-DRG,7020.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11619.48,102,MS-DRG,9295.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8775.71,100,CUSTOM-DRG,7020.57,Case rate,100% of GA Medicaid ,11391.65,100,MS-DRG,9113.32,Case rate,100% of Medicare MS-DRG,8775.71,100,CUSTOM-DRG,7020.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8775.71,100,CUSTOM-DRG,7020.57,Case rate,100% of GA Medicaid ,8775.71,11619.48,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5363.49,100,CUSTOM-DRG,4290.79,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7414.26,102,MS-DRG,5931.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5363.49,100,CUSTOM-DRG,4290.79,Case rate,100% of GA Medicaid ,7268.88,100,MS-DRG,5815.1,Case rate,100% of Medicare MS-DRG,5363.49,100,CUSTOM-DRG,4290.79,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5363.49,100,CUSTOM-DRG,4290.79,Case rate,100% of GA Medicaid ,5363.49,7414.26,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10605.64,100,CUSTOM-DRG,8484.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14049.4,102,MS-DRG,11239.52,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10605.64,100,CUSTOM-DRG,8484.51,Case rate,100% of GA Medicaid ,13773.92,100,MS-DRG,11019.14,Case rate,100% of Medicare MS-DRG,10605.64,100,CUSTOM-DRG,8484.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10605.64,100,CUSTOM-DRG,8484.51,Case rate,100% of GA Medicaid ,10605.64,14049.4,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8168.5,100,CUSTOM-DRG,6534.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8528.15,102,MS-DRG,6822.52,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8168.5,100,CUSTOM-DRG,6534.8,Case rate,100% of GA Medicaid ,8360.93,100,MS-DRG,6688.74,Case rate,100% of Medicare MS-DRG,8168.5,100,CUSTOM-DRG,6534.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8168.5,100,CUSTOM-DRG,6534.8,Case rate,100% of GA Medicaid ,8168.5,8528.15,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4029.4,100,CUSTOM-DRG,3223.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7073.79,102,MS-DRG,5659.03,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4029.4,100,CUSTOM-DRG,3223.52,Case rate,100% of GA Medicaid ,6935.09,100,MS-DRG,5548.07,Case rate,100% of Medicare MS-DRG,4029.4,100,CUSTOM-DRG,3223.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4029.4,100,CUSTOM-DRG,3223.52,Case rate,100% of GA Medicaid ,4029.4,7073.79,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9875.44,100,CUSTOM-DRG,7900.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14395.59,102,MS-DRG,11516.47,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9875.44,100,CUSTOM-DRG,7900.35,Case rate,100% of GA Medicaid ,14113.32,100,MS-DRG,11290.66,Case rate,100% of Medicare MS-DRG,9875.44,100,CUSTOM-DRG,7900.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9875.44,100,CUSTOM-DRG,7900.35,Case rate,100% of GA Medicaid ,9875.44,14395.59,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7357.97,100,CUSTOM-DRG,5886.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9272.92,102,MS-DRG,7418.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7357.97,100,CUSTOM-DRG,5886.38,Case rate,100% of GA Medicaid ,9091.1,100,MS-DRG,7272.88,Case rate,100% of Medicare MS-DRG,7357.97,100,CUSTOM-DRG,5886.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7357.97,100,CUSTOM-DRG,5886.38,Case rate,100% of GA Medicaid ,7357.97,9272.92,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4197.27,100,CUSTOM-DRG,3357.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7304.9,102,MS-DRG,5843.92,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4197.27,100,CUSTOM-DRG,3357.82,Case rate,100% of GA Medicaid ,7161.67,100,MS-DRG,5729.34,Case rate,100% of Medicare MS-DRG,4197.27,100,CUSTOM-DRG,3357.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4197.27,100,CUSTOM-DRG,3357.82,Case rate,100% of GA Medicaid ,4197.27,7304.9,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7273.2,100,CUSTOM-DRG,5818.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13039.84,102,MS-DRG,10431.87,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7273.2,100,CUSTOM-DRG,5818.56,Case rate,100% of GA Medicaid ,12784.16,100,MS-DRG,10227.33,Case rate,100% of Medicare MS-DRG,7273.2,100,CUSTOM-DRG,5818.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7273.2,100,CUSTOM-DRG,5818.56,Case rate,100% of GA Medicaid ,7273.2,13039.84,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4621.1,100,CUSTOM-DRG,3696.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8952.62,102,MS-DRG,7162.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4621.1,100,CUSTOM-DRG,3696.88,Case rate,100% of GA Medicaid ,8777.08,100,MS-DRG,7021.66,Case rate,100% of Medicare MS-DRG,4621.1,100,CUSTOM-DRG,3696.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4621.1,100,CUSTOM-DRG,3696.88,Case rate,100% of GA Medicaid ,4621.1,8952.62,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2857.09,100,CUSTOM-DRG,2285.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7024.3,102,MS-DRG,5619.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2857.09,100,CUSTOM-DRG,2285.67,Case rate,100% of GA Medicaid ,6886.57,100,MS-DRG,5509.26,Case rate,100% of Medicare MS-DRG,2857.09,100,CUSTOM-DRG,2285.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2857.09,100,CUSTOM-DRG,2285.67,Case rate,100% of GA Medicaid ,2857.09,7024.3,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9025.02,100,CUSTOM-DRG,7220.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12854.32,102,MS-DRG,10283.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9025.02,100,CUSTOM-DRG,7220.02,Case rate,100% of GA Medicaid ,12602.27,100,MS-DRG,10081.82,Case rate,100% of Medicare MS-DRG,9025.02,100,CUSTOM-DRG,7220.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9025.02,100,CUSTOM-DRG,7220.02,Case rate,100% of GA Medicaid ,9025.02,12854.32,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6429.98,100,CUSTOM-DRG,5143.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8590.64,102,MS-DRG,6872.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6429.98,100,CUSTOM-DRG,5143.98,Case rate,100% of GA Medicaid ,8422.2,100,MS-DRG,6737.76,Case rate,100% of Medicare MS-DRG,6429.98,100,CUSTOM-DRG,5143.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6429.98,100,CUSTOM-DRG,5143.98,Case rate,100% of GA Medicaid ,6429.98,8590.64,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3587.85,100,CUSTOM-DRG,2870.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6964.42,102,MS-DRG,5571.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3587.85,100,CUSTOM-DRG,2870.28,Case rate,100% of GA Medicaid ,6827.86,100,MS-DRG,5462.29,Case rate,100% of Medicare MS-DRG,3587.85,100,CUSTOM-DRG,2870.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3587.85,100,CUSTOM-DRG,2870.28,Case rate,100% of GA Medicaid ,3587.85,6964.42,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10203.29,102,MS-DRG,8162.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,10003.23,100,MS-DRG,8002.58,Case rate,100% of Medicare MS-DRG,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,7772.37,10203.29,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6205.6,100,CUSTOM-DRG,4964.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9278.78,102,MS-DRG,7423.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6205.6,100,CUSTOM-DRG,4964.48,Case rate,100% of GA Medicaid ,9096.84,100,MS-DRG,7277.47,Case rate,100% of Medicare MS-DRG,6205.6,100,CUSTOM-DRG,4964.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6205.6,100,CUSTOM-DRG,4964.48,Case rate,100% of GA Medicaid ,6205.6,9278.78,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4967.92,100,CUSTOM-DRG,3974.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7631.71,102,MS-DRG,6105.37,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4967.92,100,CUSTOM-DRG,3974.34,Case rate,100% of GA Medicaid ,7482.07,100,MS-DRG,5985.66,Case rate,100% of Medicare MS-DRG,4967.92,100,CUSTOM-DRG,3974.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4967.92,100,CUSTOM-DRG,3974.34,Case rate,100% of GA Medicaid ,4967.92,7631.71,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3896.99,100,CUSTOM-DRG,3117.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6282.8,102,MS-DRG,5026.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3896.99,100,CUSTOM-DRG,3117.59,Case rate,100% of GA Medicaid ,6159.61,100,MS-DRG,4927.69,Case rate,100% of Medicare MS-DRG,3896.99,100,CUSTOM-DRG,3117.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3896.99,100,CUSTOM-DRG,3117.59,Case rate,100% of GA Medicaid ,3896.99,6282.8,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7444.95,100,CUSTOM-DRG,5955.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10986.76,102,MS-DRG,8789.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7444.95,100,CUSTOM-DRG,5955.96,Case rate,100% of GA Medicaid ,10771.33,100,MS-DRG,8617.06,Case rate,100% of Medicare MS-DRG,7444.95,100,CUSTOM-DRG,5955.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7444.95,100,CUSTOM-DRG,5955.96,Case rate,100% of GA Medicaid ,7444.95,10986.76,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5152.96,100,CUSTOM-DRG,4122.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7457.22,102,MS-DRG,5965.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5152.96,100,CUSTOM-DRG,4122.37,Case rate,100% of GA Medicaid ,7311,100,MS-DRG,5848.8,Case rate,100% of Medicare MS-DRG,5152.96,100,CUSTOM-DRG,4122.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5152.96,100,CUSTOM-DRG,4122.37,Case rate,100% of GA Medicaid ,5152.96,7457.22,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3884.8,100,CUSTOM-DRG,3107.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6177.33,102,MS-DRG,4941.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3884.8,100,CUSTOM-DRG,3107.84,Case rate,100% of GA Medicaid ,6056.21,100,MS-DRG,4844.97,Case rate,100% of Medicare MS-DRG,3884.8,100,CUSTOM-DRG,3107.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3884.8,100,CUSTOM-DRG,3107.84,Case rate,100% of GA Medicaid ,3884.8,6177.33,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7201.18,100,CUSTOM-DRG,5760.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15697.49,102,MS-DRG,12557.99,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7201.18,100,CUSTOM-DRG,5760.94,Case rate,100% of GA Medicaid ,15389.7,100,MS-DRG,12311.76,Case rate,100% of Medicare MS-DRG,7201.18,100,CUSTOM-DRG,5760.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7201.18,100,CUSTOM-DRG,5760.94,Case rate,100% of GA Medicaid ,7201.18,15697.49,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5662.66,100,CUSTOM-DRG,4530.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8598.46,102,MS-DRG,6878.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5662.66,100,CUSTOM-DRG,4530.13,Case rate,100% of GA Medicaid ,8429.86,100,MS-DRG,6743.89,Case rate,100% of Medicare MS-DRG,5662.66,100,CUSTOM-DRG,4530.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5662.66,100,CUSTOM-DRG,4530.13,Case rate,100% of GA Medicaid ,5662.66,8598.46,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3757.93,100,CUSTOM-DRG,3006.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7170.79,102,MS-DRG,5736.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3757.93,100,CUSTOM-DRG,3006.34,Case rate,100% of GA Medicaid ,7030.19,100,MS-DRG,5624.15,Case rate,100% of Medicare MS-DRG,3757.93,100,CUSTOM-DRG,3006.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3757.93,100,CUSTOM-DRG,3006.34,Case rate,100% of GA Medicaid ,3757.93,7170.79,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8389,100,CUSTOM-DRG,6711.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14692.91,102,MS-DRG,11754.33,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8389,100,CUSTOM-DRG,6711.2,Case rate,100% of GA Medicaid ,14404.81,100,MS-DRG,11523.85,Case rate,100% of Medicare MS-DRG,8389,100,CUSTOM-DRG,6711.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8389,100,CUSTOM-DRG,6711.2,Case rate,100% of GA Medicaid ,8389,14692.91,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4223.31,100,CUSTOM-DRG,3378.65,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9116.02,102,MS-DRG,7292.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4223.31,100,CUSTOM-DRG,3378.65,Case rate,100% of GA Medicaid ,8937.27,100,MS-DRG,7149.82,Case rate,100% of Medicare MS-DRG,4223.31,100,CUSTOM-DRG,3378.65,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4223.31,100,CUSTOM-DRG,3378.65,Case rate,100% of GA Medicaid ,4223.31,9116.02,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3415.55,100,CUSTOM-DRG,2732.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6701.4,102,MS-DRG,5361.12,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3415.55,100,CUSTOM-DRG,2732.44,Case rate,100% of GA Medicaid ,6570,100,MS-DRG,5256,Case rate,100% of Medicare MS-DRG,3415.55,100,CUSTOM-DRG,2732.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3415.55,100,CUSTOM-DRG,2732.44,Case rate,100% of GA Medicaid ,3415.55,6701.4,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4792.29,100,CUSTOM-DRG,3833.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8338.06,102,MS-DRG,6670.45,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4792.29,100,CUSTOM-DRG,3833.83,Case rate,100% of GA Medicaid ,8174.57,100,MS-DRG,6539.66,Case rate,100% of Medicare MS-DRG,4792.29,100,CUSTOM-DRG,3833.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4792.29,100,CUSTOM-DRG,3833.83,Case rate,100% of GA Medicaid ,4792.29,8338.06,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3435.49,100,CUSTOM-DRG,2748.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6628.48,102,MS-DRG,5302.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3435.49,100,CUSTOM-DRG,2748.39,Case rate,100% of GA Medicaid ,6498.51,100,MS-DRG,5198.81,Case rate,100% of Medicare MS-DRG,3435.49,100,CUSTOM-DRG,2748.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3435.49,100,CUSTOM-DRG,2748.39,Case rate,100% of GA Medicaid ,3435.49,6628.48,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4416.11,100,CUSTOM-DRG,3532.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7461.8,102,MS-DRG,5969.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4416.11,100,CUSTOM-DRG,3532.89,Case rate,100% of GA Medicaid ,7315.49,100,MS-DRG,5852.39,Case rate,100% of Medicare MS-DRG,4416.11,100,CUSTOM-DRG,3532.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4416.11,100,CUSTOM-DRG,3532.89,Case rate,100% of GA Medicaid ,4416.11,7461.8,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6488.71,100,CUSTOM-DRG,5190.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14992.71,102,MS-DRG,11994.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6488.71,100,CUSTOM-DRG,5190.97,Case rate,100% of GA Medicaid ,14698.74,100,MS-DRG,11758.99,Case rate,100% of Medicare MS-DRG,6488.71,100,CUSTOM-DRG,5190.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6488.71,100,CUSTOM-DRG,5190.97,Case rate,100% of GA Medicaid ,6488.71,14992.71,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3807.79,100,CUSTOM-DRG,3046.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8051.6,102,MS-DRG,6441.28,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3807.79,100,CUSTOM-DRG,3046.23,Case rate,100% of GA Medicaid ,7893.73,100,MS-DRG,6314.98,Case rate,100% of Medicare MS-DRG,3807.79,100,CUSTOM-DRG,3046.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3807.79,100,CUSTOM-DRG,3046.23,Case rate,100% of GA Medicaid ,3807.79,8051.6,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38706.19,100,CUSTOM-DRG,30964.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,57211.29,102,MS-DRG,45769.03,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,38706.19,100,CUSTOM-DRG,30964.95,Case rate,100% of GA Medicaid ,56089.5,100,MS-DRG,44871.6,Case rate,100% of Medicare MS-DRG,38706.19,100,CUSTOM-DRG,30964.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,38706.19,100,CUSTOM-DRG,30964.95,Case rate,100% of GA Medicaid ,38706.19,57211.29,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11780.17,100,CUSTOM-DRG,9424.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22392.58,102,MS-DRG,17914.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11780.17,100,CUSTOM-DRG,9424.14,Case rate,100% of GA Medicaid ,21953.51,100,MS-DRG,17562.81,Case rate,100% of Medicare MS-DRG,11780.17,100,CUSTOM-DRG,9424.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11780.17,100,CUSTOM-DRG,9424.14,Case rate,100% of GA Medicaid ,11780.17,22392.58,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3029.39,100,CUSTOM-DRG,2423.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,89201.74,102,MS-DRG,71361.39,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3029.39,100,CUSTOM-DRG,2423.51,Case rate,100% of GA Medicaid ,87452.69,100,MS-DRG,69962.15,Case rate,100% of Medicare MS-DRG,3029.39,100,CUSTOM-DRG,2423.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3029.39,100,CUSTOM-DRG,2423.51,Case rate,100% of GA Medicaid ,3029.39,89201.74,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,71098.2,100,CUSTOM-DRG,56878.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,84597.84,102,MS-DRG,67678.27,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,71098.2,100,CUSTOM-DRG,56878.56,Case rate,100% of GA Medicaid ,82939.06,100,MS-DRG,66351.25,Case rate,100% of Medicare MS-DRG,71098.2,100,CUSTOM-DRG,56878.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,71098.2,100,CUSTOM-DRG,56878.56,Case rate,100% of GA Medicaid ,71098.2,84597.84,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,59490.88,100,CUSTOM-DRG,47592.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,80378.22,102,MS-DRG,64302.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,59490.88,100,CUSTOM-DRG,47592.7,Case rate,100% of GA Medicaid ,78802.18,100,MS-DRG,63041.74,Case rate,100% of Medicare MS-DRG,59490.88,100,CUSTOM-DRG,47592.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,59490.88,100,CUSTOM-DRG,47592.7,Case rate,100% of GA Medicaid ,59490.88,80378.22,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,34839.12,100,CUSTOM-DRG,27871.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,52716.71,102,MS-DRG,42173.37,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,34839.12,100,CUSTOM-DRG,27871.3,Case rate,100% of GA Medicaid ,51683.05,100,MS-DRG,41346.44,Case rate,100% of Medicare MS-DRG,34839.12,100,CUSTOM-DRG,27871.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,34839.12,100,CUSTOM-DRG,27871.3,Case rate,100% of GA Medicaid ,34839.12,52716.71,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27791.96,100,CUSTOM-DRG,22233.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,47179.44,102,MS-DRG,37743.55,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27791.96,100,CUSTOM-DRG,22233.57,Case rate,100% of GA Medicaid ,46254.35,100,MS-DRG,37003.48,Case rate,100% of Medicare MS-DRG,27791.96,100,CUSTOM-DRG,22233.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27791.96,100,CUSTOM-DRG,22233.57,Case rate,100% of GA Medicaid ,27791.96,47179.44,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38502.31,100,CUSTOM-DRG,30801.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,63863.3,102,MS-DRG,51090.64,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,38502.31,100,CUSTOM-DRG,30801.85,Case rate,100% of GA Medicaid ,62611.08,100,MS-DRG,50088.86,Case rate,100% of Medicare MS-DRG,38502.31,100,CUSTOM-DRG,30801.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,38502.31,100,CUSTOM-DRG,30801.85,Case rate,100% of GA Medicaid ,38502.31,63863.3,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30775.37,100,CUSTOM-DRG,24620.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,43435.18,102,MS-DRG,34748.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,30775.37,100,CUSTOM-DRG,24620.3,Case rate,100% of GA Medicaid ,42583.51,100,MS-DRG,34066.81,Case rate,100% of Medicare MS-DRG,30775.37,100,CUSTOM-DRG,24620.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30775.37,100,CUSTOM-DRG,24620.3,Case rate,100% of GA Medicaid ,30775.37,43435.18,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30180.35,100,CUSTOM-DRG,24144.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,38499.19,102,MS-DRG,30799.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,30180.35,100,CUSTOM-DRG,24144.28,Case rate,100% of GA Medicaid ,37744.3,100,MS-DRG,30195.44,Case rate,100% of Medicare MS-DRG,30180.35,100,CUSTOM-DRG,24144.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30180.35,100,CUSTOM-DRG,24144.28,Case rate,100% of GA Medicaid ,30180.35,38499.19,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,31620.25,100,CUSTOM-DRG,25296.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,41729.95,102,MS-DRG,33383.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,31620.25,100,CUSTOM-DRG,25296.2,Case rate,100% of GA Medicaid ,40911.72,100,MS-DRG,32729.38,Case rate,100% of Medicare MS-DRG,31620.25,100,CUSTOM-DRG,25296.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,31620.25,100,CUSTOM-DRG,25296.2,Case rate,100% of GA Medicaid ,31620.25,41729.95,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20231.78,100,CUSTOM-DRG,16185.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26333.1,102,MS-DRG,21066.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,20231.78,100,CUSTOM-DRG,16185.42,Case rate,100% of GA Medicaid ,25816.76,100,MS-DRG,20653.41,Case rate,100% of Medicare MS-DRG,20231.78,100,CUSTOM-DRG,16185.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20231.78,100,CUSTOM-DRG,16185.42,Case rate,100% of GA Medicaid ,20231.78,26333.1,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,36462.4,100,CUSTOM-DRG,29169.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,67209.19,102,MS-DRG,53767.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,36462.4,100,CUSTOM-DRG,29169.92,Case rate,100% of GA Medicaid ,65891.36,100,MS-DRG,52713.09,Case rate,100% of Medicare MS-DRG,36462.4,100,CUSTOM-DRG,29169.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,36462.4,100,CUSTOM-DRG,29169.92,Case rate,100% of GA Medicaid ,36462.4,67209.19,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30833.54,100,CUSTOM-DRG,24666.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,49265.64,102,MS-DRG,39412.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,30833.54,100,CUSTOM-DRG,24666.83,Case rate,100% of GA Medicaid ,48299.65,100,MS-DRG,38639.72,Case rate,100% of Medicare MS-DRG,30833.54,100,CUSTOM-DRG,24666.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30833.54,100,CUSTOM-DRG,24666.83,Case rate,100% of GA Medicaid ,30833.54,49265.64,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,36069.6,100,CUSTOM-DRG,28855.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,64595.43,102,MS-DRG,51676.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,36069.6,100,CUSTOM-DRG,28855.68,Case rate,100% of GA Medicaid ,63328.85,100,MS-DRG,50663.08,Case rate,100% of Medicare MS-DRG,36069.6,100,CUSTOM-DRG,28855.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,36069.6,100,CUSTOM-DRG,28855.68,Case rate,100% of GA Medicaid ,36069.6,64595.43,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25065.06,100,CUSTOM-DRG,20052.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,43048.43,102,MS-DRG,34438.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,25065.06,100,CUSTOM-DRG,20052.05,Case rate,100% of GA Medicaid ,42204.34,100,MS-DRG,33763.47,Case rate,100% of Medicare MS-DRG,25065.06,100,CUSTOM-DRG,20052.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25065.06,100,CUSTOM-DRG,20052.05,Case rate,100% of GA Medicaid ,25065.06,43048.43,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,29750.43,100,CUSTOM-DRG,23800.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,48702.48,102,MS-DRG,38961.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,29750.43,100,CUSTOM-DRG,23800.34,Case rate,100% of GA Medicaid ,47747.53,100,MS-DRG,38198.02,Case rate,100% of Medicare MS-DRG,29750.43,100,CUSTOM-DRG,23800.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29750.43,100,CUSTOM-DRG,23800.34,Case rate,100% of GA Medicaid ,29750.43,48702.48,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21548.69,100,CUSTOM-DRG,17238.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,33468.77,102,MS-DRG,26775.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,21548.69,100,CUSTOM-DRG,17238.95,Case rate,100% of GA Medicaid ,32812.52,100,MS-DRG,26250.02,Case rate,100% of Medicare MS-DRG,21548.69,100,CUSTOM-DRG,17238.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21548.69,100,CUSTOM-DRG,17238.95,Case rate,100% of GA Medicaid ,21548.69,33468.77,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30693.37,100,CUSTOM-DRG,24554.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,39809.39,102,MS-DRG,31847.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,30693.37,100,CUSTOM-DRG,24554.7,Case rate,100% of GA Medicaid ,39028.81,100,MS-DRG,31223.05,Case rate,100% of Medicare MS-DRG,30693.37,100,CUSTOM-DRG,24554.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30693.37,100,CUSTOM-DRG,24554.7,Case rate,100% of GA Medicaid ,30693.37,39809.39,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14888.23,100,CUSTOM-DRG,11910.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23265.49,102,MS-DRG,18612.39,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14888.23,100,CUSTOM-DRG,11910.58,Case rate,100% of GA Medicaid ,22809.3,100,MS-DRG,18247.44,Case rate,100% of Medicare MS-DRG,14888.23,100,CUSTOM-DRG,11910.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14888.23,100,CUSTOM-DRG,11910.58,Case rate,100% of GA Medicaid ,14888.23,23265.49,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6267.65,100,CUSTOM-DRG,5014.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11544.95,102,MS-DRG,9235.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6267.65,100,CUSTOM-DRG,5014.12,Case rate,100% of GA Medicaid ,11318.58,100,MS-DRG,9054.86,Case rate,100% of Medicare MS-DRG,6267.65,100,CUSTOM-DRG,5014.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6267.65,100,CUSTOM-DRG,5014.12,Case rate,100% of GA Medicaid ,6267.65,11544.95,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23567.54,100,CUSTOM-DRG,18854.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28614.75,102,MS-DRG,22891.8,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,23567.54,100,CUSTOM-DRG,18854.03,Case rate,100% of GA Medicaid ,28053.68,100,MS-DRG,22442.94,Case rate,100% of Medicare MS-DRG,23567.54,100,CUSTOM-DRG,18854.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23567.54,100,CUSTOM-DRG,18854.03,Case rate,100% of GA Medicaid ,23567.54,28614.75,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15127.57,100,CUSTOM-DRG,12102.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18862.83,102,MS-DRG,15090.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15127.57,100,CUSTOM-DRG,12102.06,Case rate,100% of GA Medicaid ,18492.97,100,MS-DRG,14794.38,Case rate,100% of Medicare MS-DRG,15127.57,100,CUSTOM-DRG,12102.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15127.57,100,CUSTOM-DRG,12102.06,Case rate,100% of GA Medicaid ,15127.57,18862.83,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11723.11,100,CUSTOM-DRG,9378.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15151.71,102,MS-DRG,12121.37,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11723.11,100,CUSTOM-DRG,9378.49,Case rate,100% of GA Medicaid ,14854.62,100,MS-DRG,11883.7,Case rate,100% of Medicare MS-DRG,11723.11,100,CUSTOM-DRG,9378.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11723.11,100,CUSTOM-DRG,9378.49,Case rate,100% of GA Medicaid ,11723.11,15151.71,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27445.14,100,CUSTOM-DRG,21956.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,37528.55,102,MS-DRG,30022.84,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27445.14,100,CUSTOM-DRG,21956.11,Case rate,100% of GA Medicaid ,36792.7,100,MS-DRG,29434.16,Case rate,100% of Medicare MS-DRG,27445.14,100,CUSTOM-DRG,21956.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27445.14,100,CUSTOM-DRG,21956.11,Case rate,100% of GA Medicaid ,27445.14,37528.55,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13509.27,100,CUSTOM-DRG,10807.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19469.06,102,MS-DRG,15575.25,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13509.27,100,CUSTOM-DRG,10807.42,Case rate,100% of GA Medicaid ,19087.31,100,MS-DRG,15269.85,Case rate,100% of Medicare MS-DRG,13509.27,100,CUSTOM-DRG,10807.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13509.27,100,CUSTOM-DRG,10807.42,Case rate,100% of GA Medicaid ,13509.27,19469.06,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8265.45,100,CUSTOM-DRG,6612.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13142.52,102,MS-DRG,10514.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8265.45,100,CUSTOM-DRG,6612.36,Case rate,100% of GA Medicaid ,12884.82,100,MS-DRG,10307.86,Case rate,100% of Medicare MS-DRG,8265.45,100,CUSTOM-DRG,6612.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8265.45,100,CUSTOM-DRG,6612.36,Case rate,100% of GA Medicaid ,8265.45,13142.52,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18834.53,100,CUSTOM-DRG,15067.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27775.79,102,MS-DRG,22220.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,18834.53,100,CUSTOM-DRG,15067.62,Case rate,100% of GA Medicaid ,27231.17,100,MS-DRG,21784.94,Case rate,100% of Medicare MS-DRG,18834.53,100,CUSTOM-DRG,15067.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18834.53,100,CUSTOM-DRG,15067.62,Case rate,100% of GA Medicaid ,18834.53,27775.79,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15939.21,100,CUSTOM-DRG,12751.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21127.93,102,MS-DRG,16902.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15939.21,100,CUSTOM-DRG,12751.37,Case rate,100% of GA Medicaid ,20713.66,100,MS-DRG,16570.93,Case rate,100% of Medicare MS-DRG,15939.21,100,CUSTOM-DRG,12751.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15939.21,100,CUSTOM-DRG,12751.37,Case rate,100% of GA Medicaid ,15939.21,21127.93,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10479.33,100,CUSTOM-DRG,8383.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14369.9,102,MS-DRG,11495.92,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10479.33,100,CUSTOM-DRG,8383.46,Case rate,100% of GA Medicaid ,14088.14,100,MS-DRG,11270.51,Case rate,100% of Medicare MS-DRG,10479.33,100,CUSTOM-DRG,8383.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10479.33,100,CUSTOM-DRG,8383.46,Case rate,100% of GA Medicaid ,10479.33,14369.9,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8369.61,100,CUSTOM-DRG,6695.69,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22753.66,102,MS-DRG,18202.93,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8369.61,100,CUSTOM-DRG,6695.69,Case rate,100% of GA Medicaid ,22307.51,100,MS-DRG,17846.01,Case rate,100% of Medicare MS-DRG,8369.61,100,CUSTOM-DRG,6695.69,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8369.61,100,CUSTOM-DRG,6695.69,Case rate,100% of GA Medicaid ,8369.61,22753.66,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8178.47,100,CUSTOM-DRG,6542.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13579.81,102,MS-DRG,10863.85,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8178.47,100,CUSTOM-DRG,6542.78,Case rate,100% of GA Medicaid ,13313.54,100,MS-DRG,10650.83,Case rate,100% of Medicare MS-DRG,8178.47,100,CUSTOM-DRG,6542.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8178.47,100,CUSTOM-DRG,6542.78,Case rate,100% of GA Medicaid ,8178.47,13579.81,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4180.1,100,CUSTOM-DRG,3344.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8556.15,102,MS-DRG,6844.92,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4180.1,100,CUSTOM-DRG,3344.08,Case rate,100% of GA Medicaid ,8388.38,100,MS-DRG,6710.7,Case rate,100% of Medicare MS-DRG,4180.1,100,CUSTOM-DRG,3344.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4180.1,100,CUSTOM-DRG,3344.08,Case rate,100% of GA Medicaid ,4180.1,8556.15,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11800.67,100,CUSTOM-DRG,9440.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22432.31,102,MS-DRG,17945.85,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11800.67,100,CUSTOM-DRG,9440.54,Case rate,100% of GA Medicaid ,21992.46,100,MS-DRG,17593.97,Case rate,100% of Medicare MS-DRG,11800.67,100,CUSTOM-DRG,9440.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11800.67,100,CUSTOM-DRG,9440.54,Case rate,100% of GA Medicaid ,11800.67,22432.31,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8257.14,100,CUSTOM-DRG,6605.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15458.98,102,MS-DRG,12367.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8257.14,100,CUSTOM-DRG,6605.71,Case rate,100% of GA Medicaid ,15155.86,100,MS-DRG,12124.69,Case rate,100% of Medicare MS-DRG,8257.14,100,CUSTOM-DRG,6605.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8257.14,100,CUSTOM-DRG,6605.71,Case rate,100% of GA Medicaid ,8257.14,15458.98,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15786.86,100,CUSTOM-DRG,12629.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27456.13,102,MS-DRG,21964.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15786.86,100,CUSTOM-DRG,12629.49,Case rate,100% of GA Medicaid ,26917.77,100,MS-DRG,21534.22,Case rate,100% of Medicare MS-DRG,15786.86,100,CUSTOM-DRG,12629.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15786.86,100,CUSTOM-DRG,12629.49,Case rate,100% of GA Medicaid ,15786.86,27456.13,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8203.96,100,CUSTOM-DRG,6563.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15584.86,102,MS-DRG,12467.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8203.96,100,CUSTOM-DRG,6563.17,Case rate,100% of GA Medicaid ,15279.27,100,MS-DRG,12223.42,Case rate,100% of Medicare MS-DRG,8203.96,100,CUSTOM-DRG,6563.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8203.96,100,CUSTOM-DRG,6563.17,Case rate,100% of GA Medicaid ,8203.96,15584.86,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7472.09,100,CUSTOM-DRG,5977.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13626.2,102,MS-DRG,10900.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7472.09,100,CUSTOM-DRG,5977.67,Case rate,100% of GA Medicaid ,13359.02,100,MS-DRG,10687.22,Case rate,100% of Medicare MS-DRG,7472.09,100,CUSTOM-DRG,5977.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7472.09,100,CUSTOM-DRG,5977.67,Case rate,100% of GA Medicaid ,7472.09,13626.2,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14574.66,100,CUSTOM-DRG,11659.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23398,102,MS-DRG,18718.4,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14574.66,100,CUSTOM-DRG,11659.73,Case rate,100% of GA Medicaid ,22939.22,100,MS-DRG,18351.38,Case rate,100% of Medicare MS-DRG,14574.66,100,CUSTOM-DRG,11659.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14574.66,100,CUSTOM-DRG,11659.73,Case rate,100% of GA Medicaid ,14574.66,23398,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15181.86,100,CUSTOM-DRG,12145.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27048.65,102,MS-DRG,21638.92,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15181.86,100,CUSTOM-DRG,12145.49,Case rate,100% of GA Medicaid ,26518.28,100,MS-DRG,21214.62,Case rate,100% of Medicare MS-DRG,15181.86,100,CUSTOM-DRG,12145.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15181.86,100,CUSTOM-DRG,12145.49,Case rate,100% of GA Medicaid ,15181.86,27048.65,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13863.85,100,CUSTOM-DRG,11091.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29269.03,102,MS-DRG,23415.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13863.85,100,CUSTOM-DRG,11091.08,Case rate,100% of GA Medicaid ,28695.13,100,MS-DRG,22956.1,Case rate,100% of Medicare MS-DRG,13863.85,100,CUSTOM-DRG,11091.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13863.85,100,CUSTOM-DRG,11091.08,Case rate,100% of GA Medicaid ,13863.85,29269.03,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26706.08,100,CUSTOM-DRG,21364.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,51729.51,102,MS-DRG,41383.61,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,26706.08,100,CUSTOM-DRG,21364.86,Case rate,100% of GA Medicaid ,50715.21,100,MS-DRG,40572.17,Case rate,100% of Medicare MS-DRG,26706.08,100,CUSTOM-DRG,21364.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26706.08,100,CUSTOM-DRG,21364.86,Case rate,100% of GA Medicaid ,26706.08,51729.51,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3049.34,100,CUSTOM-DRG,2439.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,40417.27,102,MS-DRG,32333.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3049.34,100,CUSTOM-DRG,2439.47,Case rate,100% of GA Medicaid ,39624.77,100,MS-DRG,31699.82,Case rate,100% of Medicare MS-DRG,3049.34,100,CUSTOM-DRG,2439.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3049.34,100,CUSTOM-DRG,2439.47,Case rate,100% of GA Medicaid ,3049.34,40417.27,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14725.9,100,CUSTOM-DRG,11780.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,56769.86,102,MS-DRG,45415.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14725.9,100,CUSTOM-DRG,11780.72,Case rate,100% of GA Medicaid ,55656.73,100,MS-DRG,44525.38,Case rate,100% of Medicare MS-DRG,14725.9,100,CUSTOM-DRG,11780.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14725.9,100,CUSTOM-DRG,11780.72,Case rate,100% of GA Medicaid ,14725.9,56769.86,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2483.13,100,CUSTOM-DRG,1986.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,34441.07,102,MS-DRG,27552.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2483.13,100,CUSTOM-DRG,1986.5,Case rate,100% of GA Medicaid ,33765.75,100,MS-DRG,27012.6,Case rate,100% of Medicare MS-DRG,2483.13,100,CUSTOM-DRG,1986.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2483.13,100,CUSTOM-DRG,1986.5,Case rate,100% of GA Medicaid ,2483.13,34441.07,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,1583.95,100,CUSTOM-DRG,1267.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,41880.68,102,MS-DRG,33504.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,1583.95,100,CUSTOM-DRG,1267.16,Case rate,100% of GA Medicaid ,41059.49,100,MS-DRG,32847.59,Case rate,100% of Medicare MS-DRG,1583.95,100,CUSTOM-DRG,1267.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,1583.95,100,CUSTOM-DRG,1267.16,Case rate,100% of GA Medicaid ,1583.95,41880.68,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2975.65,100,CUSTOM-DRG,2380.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28623.86,102,MS-DRG,22899.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2975.65,100,CUSTOM-DRG,2380.52,Case rate,100% of GA Medicaid ,28062.61,100,MS-DRG,22450.09,Case rate,100% of Medicare MS-DRG,2975.65,100,CUSTOM-DRG,2380.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2975.65,100,CUSTOM-DRG,2380.52,Case rate,100% of GA Medicaid ,2975.65,28623.86,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,20203.67,102,MS-DRG,16162.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,19807.52,100,MS-DRG,15846.02,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,19807.52,20203.67,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21580.26,100,CUSTOM-DRG,17264.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32274.52,102,MS-DRG,25819.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,21580.26,100,CUSTOM-DRG,17264.21,Case rate,100% of GA Medicaid ,31641.69,100,MS-DRG,25313.35,Case rate,100% of Medicare MS-DRG,21580.26,100,CUSTOM-DRG,17264.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21580.26,100,CUSTOM-DRG,17264.21,Case rate,100% of GA Medicaid ,21580.26,32274.52,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11467.7,100,CUSTOM-DRG,9174.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26839.94,102,MS-DRG,21471.95,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11467.7,100,CUSTOM-DRG,9174.16,Case rate,100% of GA Medicaid ,26313.67,100,MS-DRG,21050.94,Case rate,100% of Medicare MS-DRG,11467.7,100,CUSTOM-DRG,9174.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11467.7,100,CUSTOM-DRG,9174.16,Case rate,100% of GA Medicaid ,11467.7,26839.94,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27733.79,100,CUSTOM-DRG,22187.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,58269.71,102,MS-DRG,46615.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27733.79,100,CUSTOM-DRG,22187.03,Case rate,100% of GA Medicaid ,57127.17,100,MS-DRG,45701.74,Case rate,100% of Medicare MS-DRG,27733.79,100,CUSTOM-DRG,22187.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27733.79,100,CUSTOM-DRG,22187.03,Case rate,100% of GA Medicaid ,27733.79,58269.71,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19820.14,100,CUSTOM-DRG,15856.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,51432.19,102,MS-DRG,41145.75,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19820.14,100,CUSTOM-DRG,15856.11,Case rate,100% of GA Medicaid ,50423.72,100,MS-DRG,40338.98,Case rate,100% of Medicare MS-DRG,19820.14,100,CUSTOM-DRG,15856.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19820.14,100,CUSTOM-DRG,15856.11,Case rate,100% of GA Medicaid ,19820.14,51432.19,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,29917.74,100,CUSTOM-DRG,23934.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,39607.3,102,MS-DRG,31685.84,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,29917.74,100,CUSTOM-DRG,23934.19,Case rate,100% of GA Medicaid ,38830.69,100,MS-DRG,31064.55,Case rate,100% of Medicare MS-DRG,29917.74,100,CUSTOM-DRG,23934.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29917.74,100,CUSTOM-DRG,23934.19,Case rate,100% of GA Medicaid ,29917.74,39607.3,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19758.09,100,CUSTOM-DRG,15806.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,36940.52,102,MS-DRG,29552.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19758.09,100,CUSTOM-DRG,15806.47,Case rate,100% of GA Medicaid ,36216.2,100,MS-DRG,28972.96,Case rate,100% of Medicare MS-DRG,19758.09,100,CUSTOM-DRG,15806.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19758.09,100,CUSTOM-DRG,15806.47,Case rate,100% of GA Medicaid ,19758.09,36940.52,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12449.43,100,CUSTOM-DRG,9959.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26507.02,102,MS-DRG,21205.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12449.43,100,CUSTOM-DRG,9959.54,Case rate,100% of GA Medicaid ,25987.27,100,MS-DRG,20789.82,Case rate,100% of Medicare MS-DRG,12449.43,100,CUSTOM-DRG,9959.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12449.43,100,CUSTOM-DRG,9959.54,Case rate,100% of GA Medicaid ,12449.43,26507.02,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9218.37,100,CUSTOM-DRG,7374.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13139.21,102,MS-DRG,10511.37,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9218.37,100,CUSTOM-DRG,7374.7,Case rate,100% of GA Medicaid ,12881.58,100,MS-DRG,10305.26,Case rate,100% of Medicare MS-DRG,9218.37,100,CUSTOM-DRG,7374.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9218.37,100,CUSTOM-DRG,7374.7,Case rate,100% of GA Medicaid ,9218.37,13139.21,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8048.36,102,MS-DRG,6438.69,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,7890.55,100,MS-DRG,6312.44,Case rate,100% of Medicare MS-DRG,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,5454.35,8048.36,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6779.52,102,MS-DRG,5423.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,6646.59,100,MS-DRG,5317.27,Case rate,100% of Medicare MS-DRG,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5454.35,100,CUSTOM-DRG,4363.48,Case rate,100% of GA Medicaid ,5454.35,6779.52,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6899.24,100,CUSTOM-DRG,5519.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16326.92,102,MS-DRG,13061.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6899.24,100,CUSTOM-DRG,5519.39,Case rate,100% of GA Medicaid ,16006.78,100,MS-DRG,12805.42,Case rate,100% of Medicare MS-DRG,6899.24,100,CUSTOM-DRG,5519.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6899.24,100,CUSTOM-DRG,5519.39,Case rate,100% of GA Medicaid ,6899.24,16326.92,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3277.59,100,CUSTOM-DRG,2622.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6920.15,102,MS-DRG,5536.12,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3277.59,100,CUSTOM-DRG,2622.07,Case rate,100% of GA Medicaid ,6784.46,100,MS-DRG,5427.57,Case rate,100% of Medicare MS-DRG,3277.59,100,CUSTOM-DRG,2622.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3277.59,100,CUSTOM-DRG,2622.07,Case rate,100% of GA Medicaid ,3277.59,6920.15,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3189.5,100,CUSTOM-DRG,2551.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5286.1,102,MS-DRG,4228.88,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3189.5,100,CUSTOM-DRG,2551.6,Case rate,100% of GA Medicaid ,5182.45,100,MS-DRG,4145.96,Case rate,100% of Medicare MS-DRG,3189.5,100,CUSTOM-DRG,2551.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3189.5,100,CUSTOM-DRG,2551.6,Case rate,100% of GA Medicaid ,3189.5,5286.1,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14277.15,100,CUSTOM-DRG,11421.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17852.45,102,MS-DRG,14281.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14277.15,100,CUSTOM-DRG,11421.72,Case rate,100% of GA Medicaid ,17502.4,100,MS-DRG,14001.92,Case rate,100% of Medicare MS-DRG,14277.15,100,CUSTOM-DRG,11421.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14277.15,100,CUSTOM-DRG,11421.72,Case rate,100% of GA Medicaid ,14277.15,17852.45,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7384.01,100,CUSTOM-DRG,5907.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9145.97,102,MS-DRG,7316.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7384.01,100,CUSTOM-DRG,5907.21,Case rate,100% of GA Medicaid ,8966.64,100,MS-DRG,7173.31,Case rate,100% of Medicare MS-DRG,7384.01,100,CUSTOM-DRG,5907.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7384.01,100,CUSTOM-DRG,5907.21,Case rate,100% of GA Medicaid ,7384.01,9145.97,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11612.3,100,CUSTOM-DRG,9289.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21474.95,102,MS-DRG,17179.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11612.3,100,CUSTOM-DRG,9289.84,Case rate,100% of GA Medicaid ,21053.87,100,MS-DRG,16843.1,Case rate,100% of Medicare MS-DRG,11612.3,100,CUSTOM-DRG,9289.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11612.3,100,CUSTOM-DRG,9289.84,Case rate,100% of GA Medicaid ,11612.3,21474.95,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7432.76,100,CUSTOM-DRG,5946.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12238.14,102,MS-DRG,9790.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7432.76,100,CUSTOM-DRG,5946.21,Case rate,100% of GA Medicaid ,11998.18,100,MS-DRG,9598.54,Case rate,100% of Medicare MS-DRG,7432.76,100,CUSTOM-DRG,5946.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7432.76,100,CUSTOM-DRG,5946.21,Case rate,100% of GA Medicaid ,7432.76,12238.14,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6801.17,100,CUSTOM-DRG,5440.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9168.75,102,MS-DRG,7335,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6801.17,100,CUSTOM-DRG,5440.94,Case rate,100% of GA Medicaid ,8988.97,100,MS-DRG,7191.18,Case rate,100% of Medicare MS-DRG,6801.17,100,CUSTOM-DRG,5440.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6801.17,100,CUSTOM-DRG,5440.94,Case rate,100% of GA Medicaid ,6801.17,9168.75,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7661.57,100,CUSTOM-DRG,6129.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10633.11,102,MS-DRG,8506.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7661.57,100,CUSTOM-DRG,6129.26,Case rate,100% of GA Medicaid ,10424.62,100,MS-DRG,8339.7,Case rate,100% of Medicare MS-DRG,7661.57,100,CUSTOM-DRG,6129.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7661.57,100,CUSTOM-DRG,6129.26,Case rate,100% of GA Medicaid ,7661.57,10633.11,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4942.98,100,CUSTOM-DRG,3954.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7680.53,102,MS-DRG,6144.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4942.98,100,CUSTOM-DRG,3954.38,Case rate,100% of GA Medicaid ,7529.93,100,MS-DRG,6023.94,Case rate,100% of Medicare MS-DRG,4942.98,100,CUSTOM-DRG,3954.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4942.98,100,CUSTOM-DRG,3954.38,Case rate,100% of GA Medicaid ,4942.98,7680.53,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3431.06,100,CUSTOM-DRG,2744.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5760.04,102,MS-DRG,4608.03,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3431.06,100,CUSTOM-DRG,2744.85,Case rate,100% of GA Medicaid ,5647.1,100,MS-DRG,4517.68,Case rate,100% of Medicare MS-DRG,3431.06,100,CUSTOM-DRG,2744.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3431.06,100,CUSTOM-DRG,2744.85,Case rate,100% of GA Medicaid ,3431.06,5760.04,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9224.74,102,MS-DRG,7379.79,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,9043.86,100,MS-DRG,7235.09,Case rate,100% of Medicare MS-DRG,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,4334.11,9224.74,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7293.83,102,MS-DRG,5835.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,7150.81,100,MS-DRG,5720.65,Case rate,100% of Medicare MS-DRG,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4334.11,100,CUSTOM-DRG,3467.29,Case rate,100% of GA Medicaid ,4334.11,7293.83,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9524.75,100,CUSTOM-DRG,7619.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13277.52,102,MS-DRG,10622.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9524.75,100,CUSTOM-DRG,7619.8,Case rate,100% of GA Medicaid ,13017.18,100,MS-DRG,10413.74,Case rate,100% of Medicare MS-DRG,9524.75,100,CUSTOM-DRG,7619.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9524.75,100,CUSTOM-DRG,7619.8,Case rate,100% of GA Medicaid ,9524.75,13277.52,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6847.88,102,MS-DRG,5478.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,6713.61,100,MS-DRG,5370.89,Case rate,100% of Medicare MS-DRG,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,2681.47,6847.88,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4967.1,102,MS-DRG,3973.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,4869.71,100,MS-DRG,3895.77,Case rate,100% of Medicare MS-DRG,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2681.47,100,CUSTOM-DRG,2145.18,Case rate,100% of GA Medicaid ,2681.47,4967.1,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6946.33,100,CUSTOM-DRG,5557.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13053.91,102,MS-DRG,10443.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6946.33,100,CUSTOM-DRG,5557.06,Case rate,100% of GA Medicaid ,12797.95,100,MS-DRG,10238.36,Case rate,100% of Medicare MS-DRG,6946.33,100,CUSTOM-DRG,5557.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6946.33,100,CUSTOM-DRG,5557.06,Case rate,100% of GA Medicaid ,6946.33,13053.91,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5723.05,100,CUSTOM-DRG,4578.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9050.92,102,MS-DRG,7240.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5723.05,100,CUSTOM-DRG,4578.44,Case rate,100% of GA Medicaid ,8873.45,100,MS-DRG,7098.76,Case rate,100% of Medicare MS-DRG,5723.05,100,CUSTOM-DRG,4578.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5723.05,100,CUSTOM-DRG,4578.44,Case rate,100% of GA Medicaid ,5723.05,9050.92,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3288.67,100,CUSTOM-DRG,2630.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6725.48,102,MS-DRG,5380.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3288.67,100,CUSTOM-DRG,2630.94,Case rate,100% of GA Medicaid ,6593.61,100,MS-DRG,5274.89,Case rate,100% of Medicare MS-DRG,3288.67,100,CUSTOM-DRG,2630.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3288.67,100,CUSTOM-DRG,2630.94,Case rate,100% of GA Medicaid ,3288.67,6725.48,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4113.61,100,CUSTOM-DRG,3290.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9403.13,102,MS-DRG,7522.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4113.61,100,CUSTOM-DRG,3290.89,Case rate,100% of GA Medicaid ,9218.75,100,MS-DRG,7375,Case rate,100% of Medicare MS-DRG,4113.61,100,CUSTOM-DRG,3290.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4113.61,100,CUSTOM-DRG,3290.89,Case rate,100% of GA Medicaid ,4113.61,9403.13,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3950.18,100,CUSTOM-DRG,3160.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6388.91,102,MS-DRG,5111.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3950.18,100,CUSTOM-DRG,3160.14,Case rate,100% of GA Medicaid ,6263.64,100,MS-DRG,5010.91,Case rate,100% of Medicare MS-DRG,3950.18,100,CUSTOM-DRG,3160.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3950.18,100,CUSTOM-DRG,3160.14,Case rate,100% of GA Medicaid ,3950.18,6388.91,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4895.34,100,CUSTOM-DRG,3916.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9584.76,102,MS-DRG,7667.81,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4895.34,100,CUSTOM-DRG,3916.27,Case rate,100% of GA Medicaid ,9396.82,100,MS-DRG,7517.46,Case rate,100% of Medicare MS-DRG,4895.34,100,CUSTOM-DRG,3916.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4895.34,100,CUSTOM-DRG,3916.27,Case rate,100% of GA Medicaid ,4895.34,9584.76,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4006.13,100,CUSTOM-DRG,3204.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7009.99,102,MS-DRG,5607.99,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4006.13,100,CUSTOM-DRG,3204.9,Case rate,100% of GA Medicaid ,6872.54,100,MS-DRG,5498.03,Case rate,100% of Medicare MS-DRG,4006.13,100,CUSTOM-DRG,3204.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4006.13,100,CUSTOM-DRG,3204.9,Case rate,100% of GA Medicaid ,4006.13,7009.99,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12727.6,102,MS-DRG,10182.08,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,12478.04,100,MS-DRG,9982.43,Case rate,100% of Medicare MS-DRG,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,4975.12,12727.6,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8241.07,102,MS-DRG,6592.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,8079.48,100,MS-DRG,6463.58,Case rate,100% of Medicare MS-DRG,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,3864.3,8241.07,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7462.68,100,CUSTOM-DRG,5970.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9956.5,102,MS-DRG,7965.2,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7462.68,100,CUSTOM-DRG,5970.14,Case rate,100% of GA Medicaid ,9761.27,100,MS-DRG,7809.02,Case rate,100% of Medicare MS-DRG,7462.68,100,CUSTOM-DRG,5970.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7462.68,100,CUSTOM-DRG,5970.14,Case rate,100% of GA Medicaid ,7462.68,9956.5,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4775.67,100,CUSTOM-DRG,3820.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6952.71,102,MS-DRG,5562.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4775.67,100,CUSTOM-DRG,3820.54,Case rate,100% of GA Medicaid ,6816.38,100,MS-DRG,5453.1,Case rate,100% of Medicare MS-DRG,4775.67,100,CUSTOM-DRG,3820.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4775.67,100,CUSTOM-DRG,3820.54,Case rate,100% of GA Medicaid ,4775.67,6952.71,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3230.5,100,CUSTOM-DRG,2584.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5704.71,102,MS-DRG,4563.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3230.5,100,CUSTOM-DRG,2584.4,Case rate,100% of GA Medicaid ,5592.85,100,MS-DRG,4474.28,Case rate,100% of Medicare MS-DRG,3230.5,100,CUSTOM-DRG,2584.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3230.5,100,CUSTOM-DRG,2584.4,Case rate,100% of GA Medicaid ,3230.5,5704.71,
ANGINA PECTORIS,311,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4049.35,100,CUSTOM-DRG,3239.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6649.32,102,MS-DRG,5319.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4049.35,100,CUSTOM-DRG,3239.48,Case rate,100% of GA Medicaid ,6518.94,100,MS-DRG,5215.15,Case rate,100% of Medicare MS-DRG,4049.35,100,CUSTOM-DRG,3239.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4049.35,100,CUSTOM-DRG,3239.48,Case rate,100% of GA Medicaid ,4049.35,6649.32,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4228.3,100,CUSTOM-DRG,3382.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7726.1,102,MS-DRG,6180.88,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4228.3,100,CUSTOM-DRG,3382.64,Case rate,100% of GA Medicaid ,7574.61,100,MS-DRG,6059.69,Case rate,100% of Medicare MS-DRG,4228.3,100,CUSTOM-DRG,3382.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4228.3,100,CUSTOM-DRG,3382.64,Case rate,100% of GA Medicaid ,4228.3,7726.1,
CHEST PAIN,313,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4142.42,100,CUSTOM-DRG,3313.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6815.32,102,MS-DRG,5452.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4142.42,100,CUSTOM-DRG,3313.94,Case rate,100% of GA Medicaid ,6681.69,100,MS-DRG,5345.35,Case rate,100% of Medicare MS-DRG,4142.42,100,CUSTOM-DRG,3313.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4142.42,100,CUSTOM-DRG,3313.94,Case rate,100% of GA Medicaid ,4142.42,6815.32,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12919.79,100,CUSTOM-DRG,10335.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17338.13,102,MS-DRG,13870.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12919.79,100,CUSTOM-DRG,10335.83,Case rate,100% of GA Medicaid ,16998.17,100,MS-DRG,13598.54,Case rate,100% of Medicare MS-DRG,12919.79,100,CUSTOM-DRG,10335.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12919.79,100,CUSTOM-DRG,10335.83,Case rate,100% of GA Medicaid ,12919.79,17338.13,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6353.52,100,CUSTOM-DRG,5082.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8401.86,102,MS-DRG,6721.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6353.52,100,CUSTOM-DRG,5082.82,Case rate,100% of GA Medicaid ,8237.12,100,MS-DRG,6589.7,Case rate,100% of Medicare MS-DRG,6353.52,100,CUSTOM-DRG,5082.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6353.52,100,CUSTOM-DRG,5082.82,Case rate,100% of GA Medicaid ,6353.52,8401.86,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4867.64,100,CUSTOM-DRG,3894.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6614.17,102,MS-DRG,5291.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4867.64,100,CUSTOM-DRG,3894.11,Case rate,100% of GA Medicaid ,6484.48,100,MS-DRG,5187.58,Case rate,100% of Medicare MS-DRG,4867.64,100,CUSTOM-DRG,3894.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4867.64,100,CUSTOM-DRG,3894.11,Case rate,100% of GA Medicaid ,4867.64,6614.17,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,36124.78,102,MS-DRG,28899.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,35416.45,100,MS-DRG,28333.16,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,35416.45,36124.78,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,18435.48,102,MS-DRG,14748.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,18074,100,MS-DRG,14459.2,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,18074,18435.48,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,23807.94,102,MS-DRG,19046.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,23341.12,100,MS-DRG,18672.9,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,23341.12,23807.94,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,15101.2,102,MS-DRG,12080.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,14805.1,100,MS-DRG,11844.08,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,14805.1,15101.2,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,34287.02,102,MS-DRG,27429.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,33614.73,100,MS-DRG,26891.78,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,33614.73,34287.02,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,24585.61,102,MS-DRG,19668.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,24103.54,100,MS-DRG,19282.83,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,24103.54,24585.61,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,21899.81,102,MS-DRG,17519.85,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,21470.4,100,MS-DRG,17176.32,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,21470.4,21899.81,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25905.51,100,CUSTOM-DRG,20724.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,42063.71,102,MS-DRG,33650.97,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,25905.51,100,CUSTOM-DRG,20724.41,Case rate,100% of GA Medicaid ,41238.93,100,MS-DRG,32991.14,Case rate,100% of Medicare MS-DRG,25905.51,100,CUSTOM-DRG,20724.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25905.51,100,CUSTOM-DRG,20724.41,Case rate,100% of GA Medicaid ,25905.51,42063.71,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12958.57,100,CUSTOM-DRG,10366.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20683.19,102,MS-DRG,16546.55,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12958.57,100,CUSTOM-DRG,10366.86,Case rate,100% of GA Medicaid ,20277.64,100,MS-DRG,16222.11,Case rate,100% of Medicare MS-DRG,12958.57,100,CUSTOM-DRG,10366.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12958.57,100,CUSTOM-DRG,10366.86,Case rate,100% of GA Medicaid ,12958.57,20683.19,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7879.3,100,CUSTOM-DRG,6303.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13228.67,102,MS-DRG,10582.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7879.3,100,CUSTOM-DRG,6303.44,Case rate,100% of GA Medicaid ,12969.28,100,MS-DRG,10375.42,Case rate,100% of Medicare MS-DRG,7879.3,100,CUSTOM-DRG,6303.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7879.3,100,CUSTOM-DRG,6303.44,Case rate,100% of GA Medicaid ,7879.3,13228.67,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27013,100,CUSTOM-DRG,21610.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,37407.64,102,MS-DRG,29926.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27013,100,CUSTOM-DRG,21610.4,Case rate,100% of GA Medicaid ,36674.16,100,MS-DRG,29339.33,Case rate,100% of Medicare MS-DRG,27013,100,CUSTOM-DRG,21610.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27013,100,CUSTOM-DRG,21610.4,Case rate,100% of GA Medicaid ,27013,37407.64,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13997.92,100,CUSTOM-DRG,11198.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19645.48,102,MS-DRG,15716.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13997.92,100,CUSTOM-DRG,11198.34,Case rate,100% of GA Medicaid ,19260.27,100,MS-DRG,15408.22,Case rate,100% of Medicare MS-DRG,13997.92,100,CUSTOM-DRG,11198.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13997.92,100,CUSTOM-DRG,11198.34,Case rate,100% of GA Medicaid ,13997.92,19645.48,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9340.26,100,CUSTOM-DRG,7472.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13847.32,102,MS-DRG,11077.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9340.26,100,CUSTOM-DRG,7472.21,Case rate,100% of GA Medicaid ,13575.8,100,MS-DRG,10860.64,Case rate,100% of Medicare MS-DRG,9340.26,100,CUSTOM-DRG,7472.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9340.26,100,CUSTOM-DRG,7472.21,Case rate,100% of GA Medicaid ,9340.26,13847.32,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19822.35,100,CUSTOM-DRG,15857.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30264.5,102,MS-DRG,24211.6,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19822.35,100,CUSTOM-DRG,15857.88,Case rate,100% of GA Medicaid ,29671.08,100,MS-DRG,23736.86,Case rate,100% of Medicare MS-DRG,19822.35,100,CUSTOM-DRG,15857.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19822.35,100,CUSTOM-DRG,15857.88,Case rate,100% of GA Medicaid ,19822.35,30264.5,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10908.69,100,CUSTOM-DRG,8726.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17222.19,102,MS-DRG,13777.75,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10908.69,100,CUSTOM-DRG,8726.95,Case rate,100% of GA Medicaid ,16884.5,100,MS-DRG,13507.6,Case rate,100% of Medicare MS-DRG,10908.69,100,CUSTOM-DRG,8726.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10908.69,100,CUSTOM-DRG,8726.95,Case rate,100% of GA Medicaid ,10908.69,17222.19,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8448.84,100,CUSTOM-DRG,6759.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13293.26,102,MS-DRG,10634.61,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8448.84,100,CUSTOM-DRG,6759.07,Case rate,100% of GA Medicaid ,13032.61,100,MS-DRG,10426.09,Case rate,100% of Medicare MS-DRG,8448.84,100,CUSTOM-DRG,6759.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8448.84,100,CUSTOM-DRG,6759.07,Case rate,100% of GA Medicaid ,8448.84,13293.26,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26859.54,100,CUSTOM-DRG,21487.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29607.74,102,MS-DRG,23686.19,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,26859.54,100,CUSTOM-DRG,21487.63,Case rate,100% of GA Medicaid ,29027.2,100,MS-DRG,23221.76,Case rate,100% of Medicare MS-DRG,26859.54,100,CUSTOM-DRG,21487.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26859.54,100,CUSTOM-DRG,21487.63,Case rate,100% of GA Medicaid ,26859.54,29607.74,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13649.44,100,CUSTOM-DRG,10919.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17435.86,102,MS-DRG,13948.69,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13649.44,100,CUSTOM-DRG,10919.55,Case rate,100% of GA Medicaid ,17093.98,100,MS-DRG,13675.18,Case rate,100% of Medicare MS-DRG,13649.44,100,CUSTOM-DRG,10919.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13649.44,100,CUSTOM-DRG,10919.55,Case rate,100% of GA Medicaid ,13649.44,17435.86,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8345.23,100,CUSTOM-DRG,6676.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12393.02,102,MS-DRG,9914.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8345.23,100,CUSTOM-DRG,6676.18,Case rate,100% of GA Medicaid ,12150.02,100,MS-DRG,9720.02,Case rate,100% of Medicare MS-DRG,8345.23,100,CUSTOM-DRG,6676.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8345.23,100,CUSTOM-DRG,6676.18,Case rate,100% of GA Medicaid ,8345.23,12393.02,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14289.34,100,CUSTOM-DRG,11431.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22695.68,102,MS-DRG,18156.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14289.34,100,CUSTOM-DRG,11431.47,Case rate,100% of GA Medicaid ,22250.67,100,MS-DRG,17800.54,Case rate,100% of Medicare MS-DRG,14289.34,100,CUSTOM-DRG,11431.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14289.34,100,CUSTOM-DRG,11431.47,Case rate,100% of GA Medicaid ,14289.34,22695.68,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7515.31,100,CUSTOM-DRG,6012.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12759.08,102,MS-DRG,10207.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7515.31,100,CUSTOM-DRG,6012.25,Case rate,100% of GA Medicaid ,12508.9,100,MS-DRG,10007.12,Case rate,100% of Medicare MS-DRG,7515.31,100,CUSTOM-DRG,6012.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7515.31,100,CUSTOM-DRG,6012.25,Case rate,100% of GA Medicaid ,7515.31,12759.08,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5355.73,100,CUSTOM-DRG,4284.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10665.42,102,MS-DRG,8532.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5355.73,100,CUSTOM-DRG,4284.58,Case rate,100% of GA Medicaid ,10456.29,100,MS-DRG,8365.03,Case rate,100% of Medicare MS-DRG,5355.73,100,CUSTOM-DRG,4284.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5355.73,100,CUSTOM-DRG,4284.58,Case rate,100% of GA Medicaid ,5355.73,10665.42,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6628.32,100,CUSTOM-DRG,5302.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21111.36,102,MS-DRG,16889.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6628.32,100,CUSTOM-DRG,5302.66,Case rate,100% of GA Medicaid ,20697.41,100,MS-DRG,16557.93,Case rate,100% of Medicare MS-DRG,6628.32,100,CUSTOM-DRG,5302.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6628.32,100,CUSTOM-DRG,5302.66,Case rate,100% of GA Medicaid ,6628.32,21111.36,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6254.35,100,CUSTOM-DRG,5003.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10778.05,102,MS-DRG,8622.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6254.35,100,CUSTOM-DRG,5003.48,Case rate,100% of GA Medicaid ,10566.72,100,MS-DRG,8453.38,Case rate,100% of Medicare MS-DRG,6254.35,100,CUSTOM-DRG,5003.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6254.35,100,CUSTOM-DRG,5003.48,Case rate,100% of GA Medicaid ,6254.35,10778.05,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4296.44,100,CUSTOM-DRG,3437.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8457.19,102,MS-DRG,6765.75,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4296.44,100,CUSTOM-DRG,3437.15,Case rate,100% of GA Medicaid ,8291.36,100,MS-DRG,6633.09,Case rate,100% of Medicare MS-DRG,4296.44,100,CUSTOM-DRG,3437.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4296.44,100,CUSTOM-DRG,3437.15,Case rate,100% of GA Medicaid ,4296.44,8457.19,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11179.06,100,CUSTOM-DRG,8943.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19876.53,102,MS-DRG,15901.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11179.06,100,CUSTOM-DRG,8943.25,Case rate,100% of GA Medicaid ,19486.79,100,MS-DRG,15589.43,Case rate,100% of Medicare MS-DRG,11179.06,100,CUSTOM-DRG,8943.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11179.06,100,CUSTOM-DRG,8943.25,Case rate,100% of GA Medicaid ,11179.06,19876.53,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7094.25,100,CUSTOM-DRG,5675.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12055.11,102,MS-DRG,9644.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7094.25,100,CUSTOM-DRG,5675.4,Case rate,100% of GA Medicaid ,11818.74,100,MS-DRG,9454.99,Case rate,100% of Medicare MS-DRG,7094.25,100,CUSTOM-DRG,5675.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7094.25,100,CUSTOM-DRG,5675.4,Case rate,100% of GA Medicaid ,7094.25,12055.11,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4413.34,100,CUSTOM-DRG,3530.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9324.35,102,MS-DRG,7459.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4413.34,100,CUSTOM-DRG,3530.67,Case rate,100% of GA Medicaid ,9141.52,100,MS-DRG,7313.22,Case rate,100% of Medicare MS-DRG,4413.34,100,CUSTOM-DRG,3530.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4413.34,100,CUSTOM-DRG,3530.67,Case rate,100% of GA Medicaid ,4413.34,9324.35,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12366.33,100,CUSTOM-DRG,9893.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24218.73,102,MS-DRG,19374.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12366.33,100,CUSTOM-DRG,9893.06,Case rate,100% of GA Medicaid ,23743.85,100,MS-DRG,18995.08,Case rate,100% of Medicare MS-DRG,12366.33,100,CUSTOM-DRG,9893.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12366.33,100,CUSTOM-DRG,9893.06,Case rate,100% of GA Medicaid ,12366.33,24218.73,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8858.81,100,CUSTOM-DRG,7087.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14226.63,102,MS-DRG,11381.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8858.81,100,CUSTOM-DRG,7087.05,Case rate,100% of GA Medicaid ,13947.68,100,MS-DRG,11158.14,Case rate,100% of Medicare MS-DRG,8858.81,100,CUSTOM-DRG,7087.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8858.81,100,CUSTOM-DRG,7087.05,Case rate,100% of GA Medicaid ,8858.81,14226.63,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6259.34,100,CUSTOM-DRG,5007.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11284.91,102,MS-DRG,9027.93,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6259.34,100,CUSTOM-DRG,5007.47,Case rate,100% of GA Medicaid ,11063.64,100,MS-DRG,8850.91,Case rate,100% of Medicare MS-DRG,6259.34,100,CUSTOM-DRG,5007.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6259.34,100,CUSTOM-DRG,5007.47,Case rate,100% of GA Medicaid ,6259.34,11284.91,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19645.07,100,CUSTOM-DRG,15716.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,35435.72,102,MS-DRG,28348.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19645.07,100,CUSTOM-DRG,15716.06,Case rate,100% of GA Medicaid ,34740.9,100,MS-DRG,27792.72,Case rate,100% of Medicare MS-DRG,19645.07,100,CUSTOM-DRG,15716.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19645.07,100,CUSTOM-DRG,15716.06,Case rate,100% of GA Medicaid ,19645.07,35435.72,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9080.97,100,CUSTOM-DRG,7264.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18193.66,102,MS-DRG,14554.93,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9080.97,100,CUSTOM-DRG,7264.78,Case rate,100% of GA Medicaid ,17836.92,100,MS-DRG,14269.54,Case rate,100% of Medicare MS-DRG,9080.97,100,CUSTOM-DRG,7264.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9080.97,100,CUSTOM-DRG,7264.78,Case rate,100% of GA Medicaid ,9080.97,18193.66,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8302.57,100,CUSTOM-DRG,6642.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10609.93,102,MS-DRG,8487.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8302.57,100,CUSTOM-DRG,6642.06,Case rate,100% of GA Medicaid ,10401.89,100,MS-DRG,8321.51,Case rate,100% of Medicare MS-DRG,8302.57,100,CUSTOM-DRG,6642.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8302.57,100,CUSTOM-DRG,6642.06,Case rate,100% of GA Medicaid ,8302.57,10609.93,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7853.26,100,CUSTOM-DRG,6282.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13681.68,102,MS-DRG,10945.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7853.26,100,CUSTOM-DRG,6282.61,Case rate,100% of GA Medicaid ,13413.41,100,MS-DRG,10730.73,Case rate,100% of Medicare MS-DRG,7853.26,100,CUSTOM-DRG,6282.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7853.26,100,CUSTOM-DRG,6282.61,Case rate,100% of GA Medicaid ,7853.26,13681.68,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6389.54,100,CUSTOM-DRG,5111.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8538.57,102,MS-DRG,6830.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6389.54,100,CUSTOM-DRG,5111.63,Case rate,100% of GA Medicaid ,8371.15,100,MS-DRG,6696.92,Case rate,100% of Medicare MS-DRG,6389.54,100,CUSTOM-DRG,5111.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6389.54,100,CUSTOM-DRG,5111.63,Case rate,100% of GA Medicaid ,6389.54,8538.57,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3223.3,100,CUSTOM-DRG,2578.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6946.18,102,MS-DRG,5556.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3223.3,100,CUSTOM-DRG,2578.64,Case rate,100% of GA Medicaid ,6809.98,100,MS-DRG,5447.98,Case rate,100% of Medicare MS-DRG,3223.3,100,CUSTOM-DRG,2578.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3223.3,100,CUSTOM-DRG,2578.64,Case rate,100% of GA Medicaid ,3223.3,6946.18,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9509.79,100,CUSTOM-DRG,7607.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14474.26,102,MS-DRG,11579.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9509.79,100,CUSTOM-DRG,7607.83,Case rate,100% of GA Medicaid ,14190.45,100,MS-DRG,11352.36,Case rate,100% of Medicare MS-DRG,9509.79,100,CUSTOM-DRG,7607.83,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9509.79,100,CUSTOM-DRG,7607.83,Case rate,100% of GA Medicaid ,9509.79,14474.26,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5576.23,100,CUSTOM-DRG,4460.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8890.12,102,MS-DRG,7112.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5576.23,100,CUSTOM-DRG,4460.98,Case rate,100% of GA Medicaid ,8715.8,100,MS-DRG,6972.64,Case rate,100% of Medicare MS-DRG,5576.23,100,CUSTOM-DRG,4460.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5576.23,100,CUSTOM-DRG,4460.98,Case rate,100% of GA Medicaid ,5576.23,8890.12,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4375.11,100,CUSTOM-DRG,3500.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6769.11,102,MS-DRG,5415.29,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4375.11,100,CUSTOM-DRG,3500.09,Case rate,100% of GA Medicaid ,6636.38,100,MS-DRG,5309.1,Case rate,100% of Medicare MS-DRG,4375.11,100,CUSTOM-DRG,3500.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4375.11,100,CUSTOM-DRG,3500.09,Case rate,100% of GA Medicaid ,4375.11,6769.11,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9311.45,100,CUSTOM-DRG,7449.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17383.69,102,MS-DRG,13906.95,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9311.45,100,CUSTOM-DRG,7449.16,Case rate,100% of GA Medicaid ,17042.83,100,MS-DRG,13634.26,Case rate,100% of Medicare MS-DRG,9311.45,100,CUSTOM-DRG,7449.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9311.45,100,CUSTOM-DRG,7449.16,Case rate,100% of GA Medicaid ,9311.45,17383.69,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7170.15,100,CUSTOM-DRG,5736.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9924.19,102,MS-DRG,7939.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7170.15,100,CUSTOM-DRG,5736.12,Case rate,100% of GA Medicaid ,9729.6,100,MS-DRG,7783.68,Case rate,100% of Medicare MS-DRG,7170.15,100,CUSTOM-DRG,5736.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7170.15,100,CUSTOM-DRG,5736.12,Case rate,100% of GA Medicaid ,7170.15,9924.19,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4464.31,100,CUSTOM-DRG,3571.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7907.73,102,MS-DRG,6326.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4464.31,100,CUSTOM-DRG,3571.45,Case rate,100% of GA Medicaid ,7752.68,100,MS-DRG,6202.14,Case rate,100% of Medicare MS-DRG,4464.31,100,CUSTOM-DRG,3571.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4464.31,100,CUSTOM-DRG,3571.45,Case rate,100% of GA Medicaid ,4464.31,7907.73,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9008.95,100,CUSTOM-DRG,7207.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14827.07,102,MS-DRG,11861.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9008.95,100,CUSTOM-DRG,7207.16,Case rate,100% of GA Medicaid ,14536.34,100,MS-DRG,11629.07,Case rate,100% of Medicare MS-DRG,9008.95,100,CUSTOM-DRG,7207.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9008.95,100,CUSTOM-DRG,7207.16,Case rate,100% of GA Medicaid ,9008.95,14827.07,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5464.87,100,CUSTOM-DRG,4371.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8509.28,102,MS-DRG,6807.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5464.87,100,CUSTOM-DRG,4371.9,Case rate,100% of GA Medicaid ,8342.43,100,MS-DRG,6673.94,Case rate,100% of Medicare MS-DRG,5464.87,100,CUSTOM-DRG,4371.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5464.87,100,CUSTOM-DRG,4371.9,Case rate,100% of GA Medicaid ,5464.87,8509.28,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4393.95,100,CUSTOM-DRG,3515.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6226.82,102,MS-DRG,4981.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4393.95,100,CUSTOM-DRG,3515.16,Case rate,100% of GA Medicaid ,6104.73,100,MS-DRG,4883.78,Case rate,100% of Medicare MS-DRG,4393.95,100,CUSTOM-DRG,3515.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4393.95,100,CUSTOM-DRG,3515.16,Case rate,100% of GA Medicaid ,4393.95,6226.82,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7045.5,100,CUSTOM-DRG,5636.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16137.26,102,MS-DRG,12909.81,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7045.5,100,CUSTOM-DRG,5636.4,Case rate,100% of GA Medicaid ,15820.84,100,MS-DRG,12656.67,Case rate,100% of Medicare MS-DRG,7045.5,100,CUSTOM-DRG,5636.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7045.5,100,CUSTOM-DRG,5636.4,Case rate,100% of GA Medicaid ,7045.5,16137.26,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5382.88,100,CUSTOM-DRG,4306.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9089.99,102,MS-DRG,7271.99,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5382.88,100,CUSTOM-DRG,4306.3,Case rate,100% of GA Medicaid ,8911.75,100,MS-DRG,7129.4,Case rate,100% of Medicare MS-DRG,5382.88,100,CUSTOM-DRG,4306.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5382.88,100,CUSTOM-DRG,4306.3,Case rate,100% of GA Medicaid ,5382.88,9089.99,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4036.05,100,CUSTOM-DRG,3228.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7033.42,102,MS-DRG,5626.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4036.05,100,CUSTOM-DRG,3228.84,Case rate,100% of GA Medicaid ,6895.51,100,MS-DRG,5516.41,Case rate,100% of Medicare MS-DRG,4036.05,100,CUSTOM-DRG,3228.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4036.05,100,CUSTOM-DRG,3228.84,Case rate,100% of GA Medicaid ,4036.05,7033.42,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6168.48,100,CUSTOM-DRG,4934.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11579.73,102,MS-DRG,9263.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6168.48,100,CUSTOM-DRG,4934.78,Case rate,100% of GA Medicaid ,11352.68,100,MS-DRG,9082.14,Case rate,100% of Medicare MS-DRG,6168.48,100,CUSTOM-DRG,4934.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6168.48,100,CUSTOM-DRG,4934.78,Case rate,100% of GA Medicaid ,6168.48,11579.73,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4424.97,100,CUSTOM-DRG,3539.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7805.53,102,MS-DRG,6244.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4424.97,100,CUSTOM-DRG,3539.98,Case rate,100% of GA Medicaid ,7652.48,100,MS-DRG,6121.98,Case rate,100% of Medicare MS-DRG,4424.97,100,CUSTOM-DRG,3539.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4424.97,100,CUSTOM-DRG,3539.98,Case rate,100% of GA Medicaid ,4424.97,7805.53,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6217.79,100,CUSTOM-DRG,4974.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12976.89,102,MS-DRG,10381.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6217.79,100,CUSTOM-DRG,4974.23,Case rate,100% of GA Medicaid ,12722.44,100,MS-DRG,10177.95,Case rate,100% of Medicare MS-DRG,6217.79,100,CUSTOM-DRG,4974.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6217.79,100,CUSTOM-DRG,4974.23,Case rate,100% of GA Medicaid ,6217.79,12976.89,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5818.34,100,CUSTOM-DRG,4654.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8429.85,102,MS-DRG,6743.88,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5818.34,100,CUSTOM-DRG,4654.67,Case rate,100% of GA Medicaid ,8264.56,100,MS-DRG,6611.65,Case rate,100% of Medicare MS-DRG,5818.34,100,CUSTOM-DRG,4654.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5818.34,100,CUSTOM-DRG,4654.67,Case rate,100% of GA Medicaid ,5818.34,8429.85,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4693.67,100,CUSTOM-DRG,3754.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6558.17,102,MS-DRG,5246.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4693.67,100,CUSTOM-DRG,3754.94,Case rate,100% of GA Medicaid ,6429.58,100,MS-DRG,5143.66,Case rate,100% of Medicare MS-DRG,4693.67,100,CUSTOM-DRG,3754.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4693.67,100,CUSTOM-DRG,3754.94,Case rate,100% of GA Medicaid ,4693.67,6558.17,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6834.42,100,CUSTOM-DRG,5467.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12037.72,102,MS-DRG,9630.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6834.42,100,CUSTOM-DRG,5467.54,Case rate,100% of GA Medicaid ,11801.69,100,MS-DRG,9441.35,Case rate,100% of Medicare MS-DRG,6834.42,100,CUSTOM-DRG,5467.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6834.42,100,CUSTOM-DRG,5467.54,Case rate,100% of GA Medicaid ,6834.42,12037.72,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4652.12,100,CUSTOM-DRG,3721.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7289.28,102,MS-DRG,5831.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4652.12,100,CUSTOM-DRG,3721.7,Case rate,100% of GA Medicaid ,7146.35,100,MS-DRG,5717.08,Case rate,100% of Medicare MS-DRG,4652.12,100,CUSTOM-DRG,3721.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4652.12,100,CUSTOM-DRG,3721.7,Case rate,100% of GA Medicaid ,4652.12,7289.28,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3259.31,100,CUSTOM-DRG,2607.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5743.75,102,MS-DRG,4595,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3259.31,100,CUSTOM-DRG,2607.45,Case rate,100% of GA Medicaid ,5631.13,100,MS-DRG,4504.9,Case rate,100% of Medicare MS-DRG,3259.31,100,CUSTOM-DRG,2607.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3259.31,100,CUSTOM-DRG,2607.45,Case rate,100% of GA Medicaid ,3259.31,5743.75,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6117.51,100,CUSTOM-DRG,4894.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10565.2,102,MS-DRG,8452.16,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6117.51,100,CUSTOM-DRG,4894.01,Case rate,100% of GA Medicaid ,10358.04,100,MS-DRG,8286.43,Case rate,100% of Medicare MS-DRG,6117.51,100,CUSTOM-DRG,4894.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6117.51,100,CUSTOM-DRG,4894.01,Case rate,100% of GA Medicaid ,6117.51,10565.2,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4125.8,100,CUSTOM-DRG,3300.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7218.96,102,MS-DRG,5775.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4125.8,100,CUSTOM-DRG,3300.64,Case rate,100% of GA Medicaid ,7077.41,100,MS-DRG,5661.93,Case rate,100% of Medicare MS-DRG,4125.8,100,CUSTOM-DRG,3300.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4125.8,100,CUSTOM-DRG,3300.64,Case rate,100% of GA Medicaid ,4125.8,7218.96,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6949.65,100,CUSTOM-DRG,5559.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13413.35,102,MS-DRG,10730.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6949.65,100,CUSTOM-DRG,5559.72,Case rate,100% of GA Medicaid ,13150.34,100,MS-DRG,10520.27,Case rate,100% of Medicare MS-DRG,6949.65,100,CUSTOM-DRG,5559.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6949.65,100,CUSTOM-DRG,5559.72,Case rate,100% of GA Medicaid ,6949.65,13413.35,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5499.22,100,CUSTOM-DRG,4399.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8203.95,102,MS-DRG,6563.16,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5499.22,100,CUSTOM-DRG,4399.38,Case rate,100% of GA Medicaid ,8043.09,100,MS-DRG,6434.47,Case rate,100% of Medicare MS-DRG,5499.22,100,CUSTOM-DRG,4399.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5499.22,100,CUSTOM-DRG,4399.38,Case rate,100% of GA Medicaid ,5499.22,8203.95,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3721.37,100,CUSTOM-DRG,2977.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6319.91,102,MS-DRG,5055.93,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3721.37,100,CUSTOM-DRG,2977.1,Case rate,100% of GA Medicaid ,6195.99,100,MS-DRG,4956.79,Case rate,100% of Medicare MS-DRG,3721.37,100,CUSTOM-DRG,2977.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3721.37,100,CUSTOM-DRG,2977.1,Case rate,100% of GA Medicaid ,3721.37,6319.91,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,18606.1,102,MS-DRG,14884.88,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,18241.27,100,MS-DRG,14593.02,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,18241.27,18606.1,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,12532.98,102,MS-DRG,10026.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,12287.24,100,MS-DRG,9829.79,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,12287.24,12532.98,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,9351.03,102,MS-DRG,7480.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,9167.68,100,MS-DRG,7334.14,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,9167.68,9351.03,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21599.66,100,CUSTOM-DRG,17279.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,45593.45,102,MS-DRG,36474.76,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,21599.66,100,CUSTOM-DRG,17279.73,Case rate,100% of GA Medicaid ,44699.46,100,MS-DRG,35759.57,Case rate,100% of Medicare MS-DRG,21599.66,100,CUSTOM-DRG,17279.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21599.66,100,CUSTOM-DRG,17279.73,Case rate,100% of GA Medicaid ,21599.66,45593.45,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15509.29,100,CUSTOM-DRG,12407.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23913.12,102,MS-DRG,19130.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15509.29,100,CUSTOM-DRG,12407.43,Case rate,100% of GA Medicaid ,23444.24,100,MS-DRG,18755.39,Case rate,100% of Medicare MS-DRG,15509.29,100,CUSTOM-DRG,12407.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15509.29,100,CUSTOM-DRG,12407.43,Case rate,100% of GA Medicaid ,15509.29,23913.12,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11410.08,100,CUSTOM-DRG,9128.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17814.34,102,MS-DRG,14251.47,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11410.08,100,CUSTOM-DRG,9128.06,Case rate,100% of GA Medicaid ,17465.04,100,MS-DRG,13972.03,Case rate,100% of Medicare MS-DRG,11410.08,100,CUSTOM-DRG,9128.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11410.08,100,CUSTOM-DRG,9128.06,Case rate,100% of GA Medicaid ,11410.08,17814.34,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17098.78,100,CUSTOM-DRG,13679.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30826.85,102,MS-DRG,24661.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17098.78,100,CUSTOM-DRG,13679.02,Case rate,100% of GA Medicaid ,30222.4,100,MS-DRG,24177.92,Case rate,100% of Medicare MS-DRG,17098.78,100,CUSTOM-DRG,13679.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17098.78,100,CUSTOM-DRG,13679.02,Case rate,100% of GA Medicaid ,17098.78,30826.85,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16210.15,102,MS-DRG,12968.12,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,15892.3,100,MS-DRG,12713.84,Case rate,100% of Medicare MS-DRG,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,11031.13,16210.15,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7775.7,100,CUSTOM-DRG,6220.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12962.8,102,MS-DRG,10370.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7775.7,100,CUSTOM-DRG,6220.56,Case rate,100% of GA Medicaid ,12708.63,100,MS-DRG,10166.9,Case rate,100% of Medicare MS-DRG,7775.7,100,CUSTOM-DRG,6220.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7775.7,100,CUSTOM-DRG,6220.56,Case rate,100% of GA Medicaid ,7775.7,12962.8,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20570.84,100,CUSTOM-DRG,16456.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25180.26,102,MS-DRG,20144.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,20570.84,100,CUSTOM-DRG,16456.67,Case rate,100% of GA Medicaid ,24686.53,100,MS-DRG,19749.22,Case rate,100% of Medicare MS-DRG,20570.84,100,CUSTOM-DRG,16456.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20570.84,100,CUSTOM-DRG,16456.67,Case rate,100% of GA Medicaid ,20570.84,25180.26,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10506.47,100,CUSTOM-DRG,8405.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17111.2,102,MS-DRG,13688.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10506.47,100,CUSTOM-DRG,8405.18,Case rate,100% of GA Medicaid ,16775.69,100,MS-DRG,13420.55,Case rate,100% of Medicare MS-DRG,10506.47,100,CUSTOM-DRG,8405.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10506.47,100,CUSTOM-DRG,8405.18,Case rate,100% of GA Medicaid ,10506.47,17111.2,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7756.31,100,CUSTOM-DRG,6205.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12502.33,102,MS-DRG,10001.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7756.31,100,CUSTOM-DRG,6205.05,Case rate,100% of GA Medicaid ,12257.19,100,MS-DRG,9805.75,Case rate,100% of Medicare MS-DRG,7756.31,100,CUSTOM-DRG,6205.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7756.31,100,CUSTOM-DRG,6205.05,Case rate,100% of GA Medicaid ,7756.31,12502.33,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20197.43,100,CUSTOM-DRG,16157.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29195.32,102,MS-DRG,23356.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,20197.43,100,CUSTOM-DRG,16157.94,Case rate,100% of GA Medicaid ,28622.86,100,MS-DRG,22898.29,Case rate,100% of Medicare MS-DRG,20197.43,100,CUSTOM-DRG,16157.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20197.43,100,CUSTOM-DRG,16157.94,Case rate,100% of GA Medicaid ,20197.43,29195.32,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9769.62,100,CUSTOM-DRG,7815.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16363.36,102,MS-DRG,13090.69,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9769.62,100,CUSTOM-DRG,7815.7,Case rate,100% of GA Medicaid ,16042.51,100,MS-DRG,12834.01,Case rate,100% of Medicare MS-DRG,9769.62,100,CUSTOM-DRG,7815.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9769.62,100,CUSTOM-DRG,7815.7,Case rate,100% of GA Medicaid ,9769.62,16363.36,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5200.05,100,CUSTOM-DRG,4160.04,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11091.11,102,MS-DRG,8872.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5200.05,100,CUSTOM-DRG,4160.04,Case rate,100% of GA Medicaid ,10873.64,100,MS-DRG,8698.91,Case rate,100% of Medicare MS-DRG,5200.05,100,CUSTOM-DRG,4160.04,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5200.05,100,CUSTOM-DRG,4160.04,Case rate,100% of GA Medicaid ,5200.05,11091.11,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12354.14,100,CUSTOM-DRG,9883.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19195.77,102,MS-DRG,15356.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12354.14,100,CUSTOM-DRG,9883.31,Case rate,100% of GA Medicaid ,18819.38,100,MS-DRG,15055.5,Case rate,100% of Medicare MS-DRG,12354.14,100,CUSTOM-DRG,9883.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12354.14,100,CUSTOM-DRG,9883.31,Case rate,100% of GA Medicaid ,12354.14,19195.77,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8380.69,100,CUSTOM-DRG,6704.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13538.4,102,MS-DRG,10830.72,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8380.69,100,CUSTOM-DRG,6704.55,Case rate,100% of GA Medicaid ,13272.94,100,MS-DRG,10618.35,Case rate,100% of Medicare MS-DRG,8380.69,100,CUSTOM-DRG,6704.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8380.69,100,CUSTOM-DRG,6704.55,Case rate,100% of GA Medicaid ,8380.69,13538.4,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6584.55,100,CUSTOM-DRG,5267.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10875.78,102,MS-DRG,8700.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6584.55,100,CUSTOM-DRG,5267.64,Case rate,100% of GA Medicaid ,10662.53,100,MS-DRG,8530.02,Case rate,100% of Medicare MS-DRG,6584.55,100,CUSTOM-DRG,5267.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6584.55,100,CUSTOM-DRG,5267.64,Case rate,100% of GA Medicaid ,6584.55,10875.78,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18917.64,100,CUSTOM-DRG,15134.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26508.68,102,MS-DRG,21206.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,18917.64,100,CUSTOM-DRG,15134.11,Case rate,100% of GA Medicaid ,25988.9,100,MS-DRG,20791.12,Case rate,100% of Medicare MS-DRG,18917.64,100,CUSTOM-DRG,15134.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18917.64,100,CUSTOM-DRG,15134.11,Case rate,100% of GA Medicaid ,18917.64,26508.68,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7544.67,100,CUSTOM-DRG,6035.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14158.71,102,MS-DRG,11326.97,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7544.67,100,CUSTOM-DRG,6035.74,Case rate,100% of GA Medicaid ,13881.09,100,MS-DRG,11104.87,Case rate,100% of Medicare MS-DRG,7544.67,100,CUSTOM-DRG,6035.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7544.67,100,CUSTOM-DRG,6035.74,Case rate,100% of GA Medicaid ,7544.67,14158.71,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6689.82,100,CUSTOM-DRG,5351.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11685.74,102,MS-DRG,9348.59,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6689.82,100,CUSTOM-DRG,5351.86,Case rate,100% of GA Medicaid ,11456.61,100,MS-DRG,9165.29,Case rate,100% of Medicare MS-DRG,6689.82,100,CUSTOM-DRG,5351.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6689.82,100,CUSTOM-DRG,5351.86,Case rate,100% of GA Medicaid ,6689.82,11685.74,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17851.14,100,CUSTOM-DRG,14280.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32389.63,102,MS-DRG,25911.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17851.14,100,CUSTOM-DRG,14280.91,Case rate,100% of GA Medicaid ,31754.54,100,MS-DRG,25403.63,Case rate,100% of Medicare MS-DRG,17851.14,100,CUSTOM-DRG,14280.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17851.14,100,CUSTOM-DRG,14280.91,Case rate,100% of GA Medicaid ,17851.14,32389.63,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10165.2,100,CUSTOM-DRG,8132.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17654.51,102,MS-DRG,14123.61,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10165.2,100,CUSTOM-DRG,8132.16,Case rate,100% of GA Medicaid ,17308.34,100,MS-DRG,13846.67,Case rate,100% of Medicare MS-DRG,10165.2,100,CUSTOM-DRG,8132.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10165.2,100,CUSTOM-DRG,8132.16,Case rate,100% of GA Medicaid ,10165.2,17654.51,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9990.68,100,CUSTOM-DRG,7992.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13266.76,102,MS-DRG,10613.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9990.68,100,CUSTOM-DRG,7992.54,Case rate,100% of GA Medicaid ,13006.63,100,MS-DRG,10405.3,Case rate,100% of Medicare MS-DRG,9990.68,100,CUSTOM-DRG,7992.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9990.68,100,CUSTOM-DRG,7992.54,Case rate,100% of GA Medicaid ,9990.68,13266.76,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10380.71,100,CUSTOM-DRG,8304.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15868.1,102,MS-DRG,12694.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10380.71,100,CUSTOM-DRG,8304.57,Case rate,100% of GA Medicaid ,15556.96,100,MS-DRG,12445.57,Case rate,100% of Medicare MS-DRG,10380.71,100,CUSTOM-DRG,8304.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10380.71,100,CUSTOM-DRG,8304.57,Case rate,100% of GA Medicaid ,10380.71,15868.1,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5223.87,100,CUSTOM-DRG,4179.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8816.55,102,MS-DRG,7053.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5223.87,100,CUSTOM-DRG,4179.1,Case rate,100% of GA Medicaid ,8643.68,100,MS-DRG,6914.94,Case rate,100% of Medicare MS-DRG,5223.87,100,CUSTOM-DRG,4179.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5223.87,100,CUSTOM-DRG,4179.1,Case rate,100% of GA Medicaid ,5223.87,8816.55,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3634.38,100,CUSTOM-DRG,2907.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6463.14,102,MS-DRG,5170.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3634.38,100,CUSTOM-DRG,2907.5,Case rate,100% of GA Medicaid ,6336.41,100,MS-DRG,5069.13,Case rate,100% of Medicare MS-DRG,3634.38,100,CUSTOM-DRG,2907.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3634.38,100,CUSTOM-DRG,2907.5,Case rate,100% of GA Medicaid ,3634.38,6463.14,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7925.84,100,CUSTOM-DRG,6340.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14575.3,102,MS-DRG,11660.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7925.84,100,CUSTOM-DRG,6340.67,Case rate,100% of GA Medicaid ,14289.51,100,MS-DRG,11431.61,Case rate,100% of Medicare MS-DRG,7925.84,100,CUSTOM-DRG,6340.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7925.84,100,CUSTOM-DRG,6340.67,Case rate,100% of GA Medicaid ,7925.84,14575.3,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5835.51,100,CUSTOM-DRG,4668.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9270.31,102,MS-DRG,7416.25,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5835.51,100,CUSTOM-DRG,4668.41,Case rate,100% of GA Medicaid ,9088.54,100,MS-DRG,7270.83,Case rate,100% of Medicare MS-DRG,5835.51,100,CUSTOM-DRG,4668.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5835.51,100,CUSTOM-DRG,4668.41,Case rate,100% of GA Medicaid ,5835.51,9270.31,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4583.42,100,CUSTOM-DRG,3666.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7515.18,102,MS-DRG,6012.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4583.42,100,CUSTOM-DRG,3666.74,Case rate,100% of GA Medicaid ,7367.82,100,MS-DRG,5894.26,Case rate,100% of Medicare MS-DRG,4583.42,100,CUSTOM-DRG,3666.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4583.42,100,CUSTOM-DRG,3666.74,Case rate,100% of GA Medicaid ,4583.42,7515.18,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9803.97,100,CUSTOM-DRG,7843.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13820.82,102,MS-DRG,11056.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9803.97,100,CUSTOM-DRG,7843.18,Case rate,100% of GA Medicaid ,13549.82,100,MS-DRG,10839.86,Case rate,100% of Medicare MS-DRG,9803.97,100,CUSTOM-DRG,7843.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9803.97,100,CUSTOM-DRG,7843.18,Case rate,100% of GA Medicaid ,9803.97,13820.82,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4978.44,100,CUSTOM-DRG,3982.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7672.06,102,MS-DRG,6137.65,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4978.44,100,CUSTOM-DRG,3982.75,Case rate,100% of GA Medicaid ,7521.63,100,MS-DRG,6017.3,Case rate,100% of Medicare MS-DRG,4978.44,100,CUSTOM-DRG,3982.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4978.44,100,CUSTOM-DRG,3982.75,Case rate,100% of GA Medicaid ,4978.44,7672.06,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6112.23,102,MS-DRG,4889.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,5992.38,100,MS-DRG,4793.9,Case rate,100% of Medicare MS-DRG,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,3645.46,6112.23,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10071.01,100,CUSTOM-DRG,8056.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15140.94,102,MS-DRG,12112.75,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10071.01,100,CUSTOM-DRG,8056.81,Case rate,100% of GA Medicaid ,14844.06,100,MS-DRG,11875.25,Case rate,100% of Medicare MS-DRG,10071.01,100,CUSTOM-DRG,8056.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10071.01,100,CUSTOM-DRG,8056.81,Case rate,100% of GA Medicaid ,10071.01,15140.94,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6067.65,100,CUSTOM-DRG,4854.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8298.99,102,MS-DRG,6639.19,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6067.65,100,CUSTOM-DRG,4854.12,Case rate,100% of GA Medicaid ,8136.26,100,MS-DRG,6509.01,Case rate,100% of Medicare MS-DRG,6067.65,100,CUSTOM-DRG,4854.12,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6067.65,100,CUSTOM-DRG,4854.12,Case rate,100% of GA Medicaid ,6067.65,8298.99,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3774.55,100,CUSTOM-DRG,3019.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6757.39,102,MS-DRG,5405.91,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3774.55,100,CUSTOM-DRG,3019.64,Case rate,100% of GA Medicaid ,6624.89,100,MS-DRG,5299.91,Case rate,100% of Medicare MS-DRG,3774.55,100,CUSTOM-DRG,3019.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3774.55,100,CUSTOM-DRG,3019.64,Case rate,100% of GA Medicaid ,3774.55,6757.39,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8466.01,100,CUSTOM-DRG,6772.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13525.99,102,MS-DRG,10820.79,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8466.01,100,CUSTOM-DRG,6772.81,Case rate,100% of GA Medicaid ,13260.77,100,MS-DRG,10608.62,Case rate,100% of Medicare MS-DRG,8466.01,100,CUSTOM-DRG,6772.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8466.01,100,CUSTOM-DRG,6772.81,Case rate,100% of GA Medicaid ,8466.01,13525.99,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6150.2,100,CUSTOM-DRG,4920.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9179.82,102,MS-DRG,7343.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6150.2,100,CUSTOM-DRG,4920.16,Case rate,100% of GA Medicaid ,8999.82,100,MS-DRG,7199.86,Case rate,100% of Medicare MS-DRG,6150.2,100,CUSTOM-DRG,4920.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6150.2,100,CUSTOM-DRG,4920.16,Case rate,100% of GA Medicaid ,6150.2,9179.82,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3903.08,100,CUSTOM-DRG,3122.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7322.47,102,MS-DRG,5857.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3903.08,100,CUSTOM-DRG,3122.46,Case rate,100% of GA Medicaid ,7178.89,100,MS-DRG,5743.11,Case rate,100% of Medicare MS-DRG,3903.08,100,CUSTOM-DRG,3122.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3903.08,100,CUSTOM-DRG,3122.46,Case rate,100% of GA Medicaid ,3903.08,7322.47,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,50582.76,100,CUSTOM-DRG,40466.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,73389.12,102,MS-DRG,58711.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,50582.76,100,CUSTOM-DRG,40466.21,Case rate,100% of GA Medicaid ,71950.12,100,MS-DRG,57560.1,Case rate,100% of Medicare MS-DRG,50582.76,100,CUSTOM-DRG,40466.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,50582.76,100,CUSTOM-DRG,40466.21,Case rate,100% of GA Medicaid ,50582.76,73389.12,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,29546.55,100,CUSTOM-DRG,23637.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,50654.52,102,MS-DRG,40523.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,29546.55,100,CUSTOM-DRG,23637.24,Case rate,100% of GA Medicaid ,49661.29,100,MS-DRG,39729.03,Case rate,100% of Medicare MS-DRG,29546.55,100,CUSTOM-DRG,23637.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29546.55,100,CUSTOM-DRG,23637.24,Case rate,100% of GA Medicaid ,29546.55,50654.52,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27195.28,100,CUSTOM-DRG,21756.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,38143.07,102,MS-DRG,30514.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,27195.28,100,CUSTOM-DRG,21756.22,Case rate,100% of GA Medicaid ,37395.17,100,MS-DRG,29916.14,Case rate,100% of Medicare MS-DRG,27195.28,100,CUSTOM-DRG,21756.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27195.28,100,CUSTOM-DRG,21756.22,Case rate,100% of GA Medicaid ,27195.28,38143.07,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,62089.25,100,CUSTOM-DRG,49671.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,69811.35,102,MS-DRG,55849.08,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,62089.25,100,CUSTOM-DRG,49671.4,Case rate,100% of GA Medicaid ,68442.5,100,MS-DRG,54754,Case rate,100% of Medicare MS-DRG,62089.25,100,CUSTOM-DRG,49671.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,62089.25,100,CUSTOM-DRG,49671.4,Case rate,100% of GA Medicaid ,62089.25,69811.35,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,43558.87,100,CUSTOM-DRG,34847.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,50314.97,102,MS-DRG,40251.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,43558.87,100,CUSTOM-DRG,34847.1,Case rate,100% of GA Medicaid ,49328.4,100,MS-DRG,39462.72,Case rate,100% of Medicare MS-DRG,43558.87,100,CUSTOM-DRG,34847.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,43558.87,100,CUSTOM-DRG,34847.1,Case rate,100% of GA Medicaid ,43558.87,50314.97,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,41799.3,100,CUSTOM-DRG,33439.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,37525.24,102,MS-DRG,30020.19,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,41799.3,100,CUSTOM-DRG,33439.44,Case rate,100% of GA Medicaid ,36789.45,100,MS-DRG,29431.56,Case rate,100% of Medicare MS-DRG,41799.3,100,CUSTOM-DRG,33439.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,41799.3,100,CUSTOM-DRG,33439.44,Case rate,100% of GA Medicaid ,36789.45,41799.3,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,49854.22,100,CUSTOM-DRG,39883.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,54927.97,102,MS-DRG,43942.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,49854.22,100,CUSTOM-DRG,39883.38,Case rate,100% of GA Medicaid ,53850.95,100,MS-DRG,43080.76,Case rate,100% of Medicare MS-DRG,49854.22,100,CUSTOM-DRG,39883.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,49854.22,100,CUSTOM-DRG,39883.38,Case rate,100% of GA Medicaid ,49854.22,54927.97,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22264.48,100,CUSTOM-DRG,17811.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30294.33,102,MS-DRG,24235.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,22264.48,100,CUSTOM-DRG,17811.58,Case rate,100% of GA Medicaid ,29700.32,100,MS-DRG,23760.26,Case rate,100% of Medicare MS-DRG,22264.48,100,CUSTOM-DRG,17811.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22264.48,100,CUSTOM-DRG,17811.58,Case rate,100% of GA Medicaid ,22264.48,30294.33,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,56470.07,102,MS-DRG,45176.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,55362.81,100,MS-DRG,44290.25,Case rate,100% of Medicare MS-DRG,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,22132.07,56470.07,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23572.74,102,MS-DRG,18858.19,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,23110.53,100,MS-DRG,18488.42,Case rate,100% of Medicare MS-DRG,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22132.07,100,CUSTOM-DRG,17705.66,Case rate,100% of GA Medicaid ,22132.07,23572.74,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,32004.19,100,CUSTOM-DRG,25603.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,46906.14,102,MS-DRG,37524.91,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,32004.19,100,CUSTOM-DRG,25603.35,Case rate,100% of GA Medicaid ,45986.41,100,MS-DRG,36789.13,Case rate,100% of Medicare MS-DRG,32004.19,100,CUSTOM-DRG,25603.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32004.19,100,CUSTOM-DRG,25603.35,Case rate,100% of GA Medicaid ,32004.19,46906.14,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16681.6,100,CUSTOM-DRG,13345.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24857.27,102,MS-DRG,19885.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16681.6,100,CUSTOM-DRG,13345.28,Case rate,100% of GA Medicaid ,24369.87,100,MS-DRG,19495.9,Case rate,100% of Medicare MS-DRG,16681.6,100,CUSTOM-DRG,13345.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16681.6,100,CUSTOM-DRG,13345.28,Case rate,100% of GA Medicaid ,16681.6,24857.27,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8129.72,100,CUSTOM-DRG,6503.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15493.76,102,MS-DRG,12395.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8129.72,100,CUSTOM-DRG,6503.78,Case rate,100% of GA Medicaid ,15189.96,100,MS-DRG,12151.97,Case rate,100% of Medicare MS-DRG,8129.72,100,CUSTOM-DRG,6503.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8129.72,100,CUSTOM-DRG,6503.78,Case rate,100% of GA Medicaid ,8129.72,15493.76,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17991.31,100,CUSTOM-DRG,14393.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,42954.84,102,MS-DRG,34363.87,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17991.31,100,CUSTOM-DRG,14393.05,Case rate,100% of GA Medicaid ,42112.59,100,MS-DRG,33690.07,Case rate,100% of Medicare MS-DRG,17991.31,100,CUSTOM-DRG,14393.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17991.31,100,CUSTOM-DRG,14393.05,Case rate,100% of GA Medicaid ,17991.31,42954.84,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16309.85,100,CUSTOM-DRG,13047.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28873.16,102,MS-DRG,23098.53,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16309.85,100,CUSTOM-DRG,13047.88,Case rate,100% of GA Medicaid ,28307.02,100,MS-DRG,22645.62,Case rate,100% of Medicare MS-DRG,16309.85,100,CUSTOM-DRG,13047.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16309.85,100,CUSTOM-DRG,13047.88,Case rate,100% of GA Medicaid ,16309.85,28873.16,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13092.09,100,CUSTOM-DRG,10473.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22109.33,102,MS-DRG,17687.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13092.09,100,CUSTOM-DRG,10473.67,Case rate,100% of GA Medicaid ,21675.81,100,MS-DRG,17340.65,Case rate,100% of Medicare MS-DRG,13092.09,100,CUSTOM-DRG,10473.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13092.09,100,CUSTOM-DRG,10473.67,Case rate,100% of GA Medicaid ,13092.09,22109.33,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15955.83,100,CUSTOM-DRG,12764.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27577.03,102,MS-DRG,22061.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15955.83,100,CUSTOM-DRG,12764.66,Case rate,100% of GA Medicaid ,27036.3,100,MS-DRG,21629.04,Case rate,100% of Medicare MS-DRG,15955.83,100,CUSTOM-DRG,12764.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15955.83,100,CUSTOM-DRG,12764.66,Case rate,100% of GA Medicaid ,15955.83,27577.03,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12011.75,100,CUSTOM-DRG,9609.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15584.03,102,MS-DRG,12467.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12011.75,100,CUSTOM-DRG,9609.4,Case rate,100% of GA Medicaid ,15278.46,100,MS-DRG,12222.77,Case rate,100% of Medicare MS-DRG,12011.75,100,CUSTOM-DRG,9609.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12011.75,100,CUSTOM-DRG,9609.4,Case rate,100% of GA Medicaid ,12011.75,15584.03,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18731.48,100,CUSTOM-DRG,14985.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,40738.62,102,MS-DRG,32590.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,18731.48,100,CUSTOM-DRG,14985.18,Case rate,100% of GA Medicaid ,39939.82,100,MS-DRG,31951.86,Case rate,100% of Medicare MS-DRG,18731.48,100,CUSTOM-DRG,14985.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18731.48,100,CUSTOM-DRG,14985.18,Case rate,100% of GA Medicaid ,18731.48,40738.62,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14469.95,100,CUSTOM-DRG,11575.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24476.3,102,MS-DRG,19581.04,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14469.95,100,CUSTOM-DRG,11575.96,Case rate,100% of GA Medicaid ,23996.37,100,MS-DRG,19197.1,Case rate,100% of Medicare MS-DRG,14469.95,100,CUSTOM-DRG,11575.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14469.95,100,CUSTOM-DRG,11575.96,Case rate,100% of GA Medicaid ,14469.95,24476.3,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11220.61,100,CUSTOM-DRG,8976.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20378.42,102,MS-DRG,16302.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11220.61,100,CUSTOM-DRG,8976.49,Case rate,100% of GA Medicaid ,19978.84,100,MS-DRG,15983.07,Case rate,100% of Medicare MS-DRG,11220.61,100,CUSTOM-DRG,8976.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11220.61,100,CUSTOM-DRG,8976.49,Case rate,100% of GA Medicaid ,11220.61,20378.42,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19362.51,100,CUSTOM-DRG,15490.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,35635.31,102,MS-DRG,28508.25,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19362.51,100,CUSTOM-DRG,15490.01,Case rate,100% of GA Medicaid ,34936.58,100,MS-DRG,27949.26,Case rate,100% of Medicare MS-DRG,19362.51,100,CUSTOM-DRG,15490.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19362.51,100,CUSTOM-DRG,15490.01,Case rate,100% of GA Medicaid ,19362.51,35635.31,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12259.95,100,CUSTOM-DRG,9807.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17762.17,102,MS-DRG,14209.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12259.95,100,CUSTOM-DRG,9807.96,Case rate,100% of GA Medicaid ,17413.89,100,MS-DRG,13931.11,Case rate,100% of Medicare MS-DRG,12259.95,100,CUSTOM-DRG,9807.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12259.95,100,CUSTOM-DRG,9807.96,Case rate,100% of GA Medicaid ,12259.95,17762.17,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5314.18,100,CUSTOM-DRG,4251.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9766.38,102,MS-DRG,7813.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5314.18,100,CUSTOM-DRG,4251.34,Case rate,100% of GA Medicaid ,9574.88,100,MS-DRG,7659.9,Case rate,100% of Medicare MS-DRG,5314.18,100,CUSTOM-DRG,4251.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5314.18,100,CUSTOM-DRG,4251.34,Case rate,100% of GA Medicaid ,5314.18,9766.38,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15586.85,100,CUSTOM-DRG,12469.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27901.68,102,MS-DRG,22321.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15586.85,100,CUSTOM-DRG,12469.48,Case rate,100% of GA Medicaid ,27354.59,100,MS-DRG,21883.67,Case rate,100% of Medicare MS-DRG,15586.85,100,CUSTOM-DRG,12469.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15586.85,100,CUSTOM-DRG,12469.48,Case rate,100% of GA Medicaid ,15586.85,27901.68,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12471.59,100,CUSTOM-DRG,9977.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19741.54,102,MS-DRG,15793.23,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12471.59,100,CUSTOM-DRG,9977.27,Case rate,100% of GA Medicaid ,19354.45,100,MS-DRG,15483.56,Case rate,100% of Medicare MS-DRG,12471.59,100,CUSTOM-DRG,9977.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12471.59,100,CUSTOM-DRG,9977.27,Case rate,100% of GA Medicaid ,12471.59,19741.54,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9372.94,100,CUSTOM-DRG,7498.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15437.45,102,MS-DRG,12349.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9372.94,100,CUSTOM-DRG,7498.35,Case rate,100% of GA Medicaid ,15134.75,100,MS-DRG,12107.8,Case rate,100% of Medicare MS-DRG,9372.94,100,CUSTOM-DRG,7498.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9372.94,100,CUSTOM-DRG,7498.35,Case rate,100% of GA Medicaid ,9372.94,15437.45,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21317.1,100,CUSTOM-DRG,17053.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24422.46,102,MS-DRG,19537.97,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,21317.1,100,CUSTOM-DRG,17053.68,Case rate,100% of GA Medicaid ,23943.59,100,MS-DRG,19154.87,Case rate,100% of Medicare MS-DRG,21317.1,100,CUSTOM-DRG,17053.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21317.1,100,CUSTOM-DRG,17053.68,Case rate,100% of GA Medicaid ,21317.1,24422.46,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12963.01,100,CUSTOM-DRG,10370.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17184.09,102,MS-DRG,13747.27,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12963.01,100,CUSTOM-DRG,10370.41,Case rate,100% of GA Medicaid ,16847.15,100,MS-DRG,13477.72,Case rate,100% of Medicare MS-DRG,12963.01,100,CUSTOM-DRG,10370.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12963.01,100,CUSTOM-DRG,10370.41,Case rate,100% of GA Medicaid ,12963.01,17184.09,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9187.35,100,CUSTOM-DRG,7349.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13154.95,102,MS-DRG,10523.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9187.35,100,CUSTOM-DRG,7349.88,Case rate,100% of GA Medicaid ,12897.01,100,MS-DRG,10317.61,Case rate,100% of Medicare MS-DRG,9187.35,100,CUSTOM-DRG,7349.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9187.35,100,CUSTOM-DRG,7349.88,Case rate,100% of GA Medicaid ,9187.35,13154.95,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12794.03,100,CUSTOM-DRG,10235.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20573.87,102,MS-DRG,16459.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12794.03,100,CUSTOM-DRG,10235.22,Case rate,100% of GA Medicaid ,20170.46,100,MS-DRG,16136.37,Case rate,100% of Medicare MS-DRG,12794.03,100,CUSTOM-DRG,10235.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12794.03,100,CUSTOM-DRG,10235.22,Case rate,100% of GA Medicaid ,12794.03,20573.87,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11270.47,100,CUSTOM-DRG,9016.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27280.54,102,MS-DRG,21824.43,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11270.47,100,CUSTOM-DRG,9016.38,Case rate,100% of GA Medicaid ,26745.63,100,MS-DRG,21396.5,Case rate,100% of Medicare MS-DRG,11270.47,100,CUSTOM-DRG,9016.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11270.47,100,CUSTOM-DRG,9016.38,Case rate,100% of GA Medicaid ,11270.47,27280.54,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10454.4,100,CUSTOM-DRG,8363.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16632.51,102,MS-DRG,13306.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10454.4,100,CUSTOM-DRG,8363.52,Case rate,100% of GA Medicaid ,16306.38,100,MS-DRG,13045.1,Case rate,100% of Medicare MS-DRG,10454.4,100,CUSTOM-DRG,8363.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10454.4,100,CUSTOM-DRG,8363.52,Case rate,100% of GA Medicaid ,10454.4,16632.51,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5735.24,100,CUSTOM-DRG,4588.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12794.69,102,MS-DRG,10235.75,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5735.24,100,CUSTOM-DRG,4588.19,Case rate,100% of GA Medicaid ,12543.81,100,MS-DRG,10035.05,Case rate,100% of Medicare MS-DRG,5735.24,100,CUSTOM-DRG,4588.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5735.24,100,CUSTOM-DRG,4588.19,Case rate,100% of GA Medicaid ,5735.24,12794.69,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8372.93,100,CUSTOM-DRG,6698.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17446.62,102,MS-DRG,13957.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8372.93,100,CUSTOM-DRG,6698.34,Case rate,100% of GA Medicaid ,17104.53,100,MS-DRG,13683.62,Case rate,100% of Medicare MS-DRG,8372.93,100,CUSTOM-DRG,6698.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8372.93,100,CUSTOM-DRG,6698.34,Case rate,100% of GA Medicaid ,8372.93,17446.62,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7478.74,100,CUSTOM-DRG,5982.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10250.5,102,MS-DRG,8200.4,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7478.74,100,CUSTOM-DRG,5982.99,Case rate,100% of GA Medicaid ,10049.51,100,MS-DRG,8039.61,Case rate,100% of Medicare MS-DRG,7478.74,100,CUSTOM-DRG,5982.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7478.74,100,CUSTOM-DRG,5982.99,Case rate,100% of GA Medicaid ,7478.74,10250.5,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17602.39,100,CUSTOM-DRG,14081.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28672.73,102,MS-DRG,22938.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17602.39,100,CUSTOM-DRG,14081.91,Case rate,100% of GA Medicaid ,28110.52,100,MS-DRG,22488.42,Case rate,100% of Medicare MS-DRG,17602.39,100,CUSTOM-DRG,14081.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17602.39,100,CUSTOM-DRG,14081.91,Case rate,100% of GA Medicaid ,17602.39,28672.73,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11858.84,100,CUSTOM-DRG,9487.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19890.61,102,MS-DRG,15912.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11858.84,100,CUSTOM-DRG,9487.07,Case rate,100% of GA Medicaid ,19500.6,100,MS-DRG,15600.48,Case rate,100% of Medicare MS-DRG,11858.84,100,CUSTOM-DRG,9487.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11858.84,100,CUSTOM-DRG,9487.07,Case rate,100% of GA Medicaid ,11858.84,19890.61,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8680.42,100,CUSTOM-DRG,6944.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15480.51,102,MS-DRG,12384.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8680.42,100,CUSTOM-DRG,6944.34,Case rate,100% of GA Medicaid ,15176.97,100,MS-DRG,12141.58,Case rate,100% of Medicare MS-DRG,8680.42,100,CUSTOM-DRG,6944.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8680.42,100,CUSTOM-DRG,6944.34,Case rate,100% of GA Medicaid ,8680.42,15480.51,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14211.22,100,CUSTOM-DRG,11368.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29659.1,102,MS-DRG,23727.28,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14211.22,100,CUSTOM-DRG,11368.98,Case rate,100% of GA Medicaid ,29077.55,100,MS-DRG,23262.04,Case rate,100% of Medicare MS-DRG,14211.22,100,CUSTOM-DRG,11368.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14211.22,100,CUSTOM-DRG,11368.98,Case rate,100% of GA Medicaid ,14211.22,29659.1,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7969.05,100,CUSTOM-DRG,6375.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16460.25,102,MS-DRG,13168.2,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7969.05,100,CUSTOM-DRG,6375.24,Case rate,100% of GA Medicaid ,16137.5,100,MS-DRG,12910,Case rate,100% of Medicare MS-DRG,7969.05,100,CUSTOM-DRG,6375.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7969.05,100,CUSTOM-DRG,6375.24,Case rate,100% of GA Medicaid ,7969.05,16460.25,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6344.66,100,CUSTOM-DRG,5075.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11821.57,102,MS-DRG,9457.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6344.66,100,CUSTOM-DRG,5075.73,Case rate,100% of GA Medicaid ,11589.77,100,MS-DRG,9271.82,Case rate,100% of Medicare MS-DRG,6344.66,100,CUSTOM-DRG,5075.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6344.66,100,CUSTOM-DRG,5075.73,Case rate,100% of GA Medicaid ,6344.66,11821.57,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10305.36,100,CUSTOM-DRG,8244.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21624.01,102,MS-DRG,17299.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10305.36,100,CUSTOM-DRG,8244.29,Case rate,100% of GA Medicaid ,21200.01,100,MS-DRG,16960.01,Case rate,100% of Medicare MS-DRG,10305.36,100,CUSTOM-DRG,8244.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10305.36,100,CUSTOM-DRG,8244.29,Case rate,100% of GA Medicaid ,10305.36,21624.01,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5529.69,100,CUSTOM-DRG,4423.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10681.97,102,MS-DRG,8545.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5529.69,100,CUSTOM-DRG,4423.75,Case rate,100% of GA Medicaid ,10472.52,100,MS-DRG,8378.02,Case rate,100% of Medicare MS-DRG,5529.69,100,CUSTOM-DRG,4423.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5529.69,100,CUSTOM-DRG,4423.75,Case rate,100% of GA Medicaid ,5529.69,10681.97,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12851.65,100,CUSTOM-DRG,10281.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26856.5,102,MS-DRG,21485.2,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12851.65,100,CUSTOM-DRG,10281.32,Case rate,100% of GA Medicaid ,26329.9,100,MS-DRG,21063.92,Case rate,100% of Medicare MS-DRG,12851.65,100,CUSTOM-DRG,10281.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12851.65,100,CUSTOM-DRG,10281.32,Case rate,100% of GA Medicaid ,12851.65,26856.5,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9833.34,100,CUSTOM-DRG,7866.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14374.87,102,MS-DRG,11499.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9833.34,100,CUSTOM-DRG,7866.67,Case rate,100% of GA Medicaid ,14093.01,100,MS-DRG,11274.41,Case rate,100% of Medicare MS-DRG,9833.34,100,CUSTOM-DRG,7866.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9833.34,100,CUSTOM-DRG,7866.67,Case rate,100% of GA Medicaid ,9833.34,14374.87,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7309.77,100,CUSTOM-DRG,5847.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11451.36,102,MS-DRG,9161.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7309.77,100,CUSTOM-DRG,5847.82,Case rate,100% of GA Medicaid ,11226.82,100,MS-DRG,8981.46,Case rate,100% of Medicare MS-DRG,7309.77,100,CUSTOM-DRG,5847.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7309.77,100,CUSTOM-DRG,5847.82,Case rate,100% of GA Medicaid ,7309.77,11451.36,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9538.04,100,CUSTOM-DRG,7630.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22211.2,102,MS-DRG,17768.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9538.04,100,CUSTOM-DRG,7630.43,Case rate,100% of GA Medicaid ,21775.69,100,MS-DRG,17420.55,Case rate,100% of Medicare MS-DRG,9538.04,100,CUSTOM-DRG,7630.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9538.04,100,CUSTOM-DRG,7630.43,Case rate,100% of GA Medicaid ,9538.04,22211.2,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8310.33,100,CUSTOM-DRG,6648.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14303.65,102,MS-DRG,11442.92,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8310.33,100,CUSTOM-DRG,6648.26,Case rate,100% of GA Medicaid ,14023.19,100,MS-DRG,11218.55,Case rate,100% of Medicare MS-DRG,8310.33,100,CUSTOM-DRG,6648.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8310.33,100,CUSTOM-DRG,6648.26,Case rate,100% of GA Medicaid ,8310.33,14303.65,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8015.04,100,CUSTOM-DRG,6412.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14126.41,102,MS-DRG,11301.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8015.04,100,CUSTOM-DRG,6412.03,Case rate,100% of GA Medicaid ,13849.42,100,MS-DRG,11079.54,Case rate,100% of Medicare MS-DRG,8015.04,100,CUSTOM-DRG,6412.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8015.04,100,CUSTOM-DRG,6412.03,Case rate,100% of GA Medicaid ,8015.04,14126.41,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5839.95,100,CUSTOM-DRG,4671.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12113.09,102,MS-DRG,9690.47,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5839.95,100,CUSTOM-DRG,4671.96,Case rate,100% of GA Medicaid ,11875.58,100,MS-DRG,9500.46,Case rate,100% of Medicare MS-DRG,5839.95,100,CUSTOM-DRG,4671.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5839.95,100,CUSTOM-DRG,4671.96,Case rate,100% of GA Medicaid ,5839.95,12113.09,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8290.39,100,CUSTOM-DRG,6632.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17654.51,102,MS-DRG,14123.61,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8290.39,100,CUSTOM-DRG,6632.31,Case rate,100% of GA Medicaid ,17308.34,100,MS-DRG,13846.67,Case rate,100% of Medicare MS-DRG,8290.39,100,CUSTOM-DRG,6632.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8290.39,100,CUSTOM-DRG,6632.31,Case rate,100% of GA Medicaid ,8290.39,17654.51,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6987.88,100,CUSTOM-DRG,5590.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11876.23,102,MS-DRG,9500.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6987.88,100,CUSTOM-DRG,5590.3,Case rate,100% of GA Medicaid ,11643.36,100,MS-DRG,9314.69,Case rate,100% of Medicare MS-DRG,6987.88,100,CUSTOM-DRG,5590.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6987.88,100,CUSTOM-DRG,5590.3,Case rate,100% of GA Medicaid ,6987.88,11876.23,
ARTHROSCOPY,509,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11420.06,100,CUSTOM-DRG,9136.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11313.89,102,MS-DRG,9051.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11420.06,100,CUSTOM-DRG,9136.05,Case rate,100% of GA Medicaid ,11092.05,100,MS-DRG,8873.64,Case rate,100% of Medicare MS-DRG,11420.06,100,CUSTOM-DRG,9136.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11420.06,100,CUSTOM-DRG,9136.05,Case rate,100% of GA Medicaid ,11092.05,11420.06,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11831.14,100,CUSTOM-DRG,9464.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22531.7,102,MS-DRG,18025.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11831.14,100,CUSTOM-DRG,9464.91,Case rate,100% of GA Medicaid ,22089.9,100,MS-DRG,17671.92,Case rate,100% of Medicare MS-DRG,11831.14,100,CUSTOM-DRG,9464.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11831.14,100,CUSTOM-DRG,9464.91,Case rate,100% of GA Medicaid ,11831.14,22531.7,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8689.28,100,CUSTOM-DRG,6951.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16512.42,102,MS-DRG,13209.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8689.28,100,CUSTOM-DRG,6951.42,Case rate,100% of GA Medicaid ,16188.65,100,MS-DRG,12950.92,Case rate,100% of Medicare MS-DRG,8689.28,100,CUSTOM-DRG,6951.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8689.28,100,CUSTOM-DRG,6951.42,Case rate,100% of GA Medicaid ,8689.28,16512.42,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5724.71,100,CUSTOM-DRG,4579.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13365.32,102,MS-DRG,10692.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5724.71,100,CUSTOM-DRG,4579.77,Case rate,100% of GA Medicaid ,13103.25,100,MS-DRG,10482.6,Case rate,100% of Medicare MS-DRG,5724.71,100,CUSTOM-DRG,4579.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5724.71,100,CUSTOM-DRG,4579.77,Case rate,100% of GA Medicaid ,5724.71,13365.32,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7340.24,100,CUSTOM-DRG,5872.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13424.94,102,MS-DRG,10739.95,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7340.24,100,CUSTOM-DRG,5872.19,Case rate,100% of GA Medicaid ,13161.71,100,MS-DRG,10529.37,Case rate,100% of Medicare MS-DRG,7340.24,100,CUSTOM-DRG,5872.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7340.24,100,CUSTOM-DRG,5872.19,Case rate,100% of GA Medicaid ,7340.24,13424.94,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6031.08,100,CUSTOM-DRG,4824.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8884.9,102,MS-DRG,7107.92,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6031.08,100,CUSTOM-DRG,4824.86,Case rate,100% of GA Medicaid ,8710.69,100,MS-DRG,6968.55,Case rate,100% of Medicare MS-DRG,6031.08,100,CUSTOM-DRG,4824.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6031.08,100,CUSTOM-DRG,4824.86,Case rate,100% of GA Medicaid ,6031.08,8884.9,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20181.36,100,CUSTOM-DRG,16145.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26183.2,102,MS-DRG,20946.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,20181.36,100,CUSTOM-DRG,16145.09,Case rate,100% of GA Medicaid ,25669.8,100,MS-DRG,20535.84,Case rate,100% of Medicare MS-DRG,20181.36,100,CUSTOM-DRG,16145.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20181.36,100,CUSTOM-DRG,16145.09,Case rate,100% of GA Medicaid ,20181.36,26183.2,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12055.52,100,CUSTOM-DRG,9644.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16901.68,102,MS-DRG,13521.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12055.52,100,CUSTOM-DRG,9644.42,Case rate,100% of GA Medicaid ,16570.27,100,MS-DRG,13256.22,Case rate,100% of Medicare MS-DRG,12055.52,100,CUSTOM-DRG,9644.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12055.52,100,CUSTOM-DRG,9644.42,Case rate,100% of GA Medicaid ,12055.52,16901.68,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11124.76,100,CUSTOM-DRG,8899.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12376.45,102,MS-DRG,9901.16,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11124.76,100,CUSTOM-DRG,8899.81,Case rate,100% of GA Medicaid ,12133.77,100,MS-DRG,9707.02,Case rate,100% of Medicare MS-DRG,11124.76,100,CUSTOM-DRG,8899.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11124.76,100,CUSTOM-DRG,8899.81,Case rate,100% of GA Medicaid ,11124.76,12376.45,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13078.24,100,CUSTOM-DRG,10462.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30243.81,102,MS-DRG,24195.05,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13078.24,100,CUSTOM-DRG,10462.59,Case rate,100% of GA Medicaid ,29650.79,100,MS-DRG,23720.63,Case rate,100% of Medicare MS-DRG,13078.24,100,CUSTOM-DRG,10462.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13078.24,100,CUSTOM-DRG,10462.59,Case rate,100% of GA Medicaid ,13078.24,30243.81,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11093.18,100,CUSTOM-DRG,8874.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16303.73,102,MS-DRG,13042.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11093.18,100,CUSTOM-DRG,8874.54,Case rate,100% of GA Medicaid ,15984.05,100,MS-DRG,12787.24,Case rate,100% of Medicare MS-DRG,11093.18,100,CUSTOM-DRG,8874.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11093.18,100,CUSTOM-DRG,8874.54,Case rate,100% of GA Medicaid ,11093.18,16303.73,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6037.73,100,CUSTOM-DRG,4830.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11855.52,102,MS-DRG,9484.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6037.73,100,CUSTOM-DRG,4830.18,Case rate,100% of GA Medicaid ,11623.06,100,MS-DRG,9298.45,Case rate,100% of Medicare MS-DRG,6037.73,100,CUSTOM-DRG,4830.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6037.73,100,CUSTOM-DRG,4830.18,Case rate,100% of GA Medicaid ,6037.73,11855.52,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,24797.64,102,MS-DRG,19838.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,24311.41,100,MS-DRG,19449.13,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,24311.41,24797.64,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,17493.01,102,MS-DRG,13994.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,17150.01,100,MS-DRG,13720.01,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,17150.01,17493.01,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5039.38,100,CUSTOM-DRG,4031.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13511.08,102,MS-DRG,10808.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5039.38,100,CUSTOM-DRG,4031.5,Case rate,100% of GA Medicaid ,13246.16,100,MS-DRG,10596.93,Case rate,100% of Medicare MS-DRG,5039.38,100,CUSTOM-DRG,4031.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5039.38,100,CUSTOM-DRG,4031.5,Case rate,100% of GA Medicaid ,5039.38,13511.08,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2656.54,100,CUSTOM-DRG,2125.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7377.8,102,MS-DRG,5902.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2656.54,100,CUSTOM-DRG,2125.23,Case rate,100% of GA Medicaid ,7233.14,100,MS-DRG,5786.51,Case rate,100% of Medicare MS-DRG,2656.54,100,CUSTOM-DRG,2125.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2656.54,100,CUSTOM-DRG,2125.23,Case rate,100% of GA Medicaid ,2656.54,7377.8,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4727.47,100,CUSTOM-DRG,3781.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10739.12,102,MS-DRG,8591.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4727.47,100,CUSTOM-DRG,3781.98,Case rate,100% of GA Medicaid ,10528.55,100,MS-DRG,8422.84,Case rate,100% of Medicare MS-DRG,4727.47,100,CUSTOM-DRG,3781.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4727.47,100,CUSTOM-DRG,3781.98,Case rate,100% of GA Medicaid ,4727.47,10739.12,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4033.83,100,CUSTOM-DRG,3227.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7228.73,102,MS-DRG,5782.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4033.83,100,CUSTOM-DRG,3227.06,Case rate,100% of GA Medicaid ,7086.99,100,MS-DRG,5669.59,Case rate,100% of Medicare MS-DRG,4033.83,100,CUSTOM-DRG,3227.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4033.83,100,CUSTOM-DRG,3227.06,Case rate,100% of GA Medicaid ,4033.83,7228.73,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3796.71,100,CUSTOM-DRG,3037.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8399.9,102,MS-DRG,6719.92,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3796.71,100,CUSTOM-DRG,3037.37,Case rate,100% of GA Medicaid ,8235.2,100,MS-DRG,6588.16,Case rate,100% of Medicare MS-DRG,3796.71,100,CUSTOM-DRG,3037.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3796.71,100,CUSTOM-DRG,3037.37,Case rate,100% of GA Medicaid ,3796.71,8399.9,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2853.21,100,CUSTOM-DRG,2282.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6720.93,102,MS-DRG,5376.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2853.21,100,CUSTOM-DRG,2282.57,Case rate,100% of GA Medicaid ,6589.15,100,MS-DRG,5271.32,Case rate,100% of Medicare MS-DRG,2853.21,100,CUSTOM-DRG,2282.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2853.21,100,CUSTOM-DRG,2282.57,Case rate,100% of GA Medicaid ,2853.21,6720.93,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9964.09,100,CUSTOM-DRG,7971.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16434.58,102,MS-DRG,13147.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9964.09,100,CUSTOM-DRG,7971.27,Case rate,100% of GA Medicaid ,16112.33,100,MS-DRG,12889.86,Case rate,100% of Medicare MS-DRG,9964.09,100,CUSTOM-DRG,7971.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9964.09,100,CUSTOM-DRG,7971.27,Case rate,100% of GA Medicaid ,9964.09,16434.58,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7191.21,100,CUSTOM-DRG,5752.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10751.55,102,MS-DRG,8601.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7191.21,100,CUSTOM-DRG,5752.97,Case rate,100% of GA Medicaid ,10540.74,100,MS-DRG,8432.59,Case rate,100% of Medicare MS-DRG,7191.21,100,CUSTOM-DRG,5752.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7191.21,100,CUSTOM-DRG,5752.97,Case rate,100% of GA Medicaid ,7191.21,10751.55,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4028.29,100,CUSTOM-DRG,3222.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7689.64,102,MS-DRG,6151.71,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4028.29,100,CUSTOM-DRG,3222.63,Case rate,100% of GA Medicaid ,7538.86,100,MS-DRG,6031.09,Case rate,100% of Medicare MS-DRG,4028.29,100,CUSTOM-DRG,3222.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4028.29,100,CUSTOM-DRG,3222.63,Case rate,100% of GA Medicaid ,4028.29,7689.64,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8145.79,100,CUSTOM-DRG,6516.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15103.68,102,MS-DRG,12082.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8145.79,100,CUSTOM-DRG,6516.63,Case rate,100% of GA Medicaid ,14807.53,100,MS-DRG,11846.02,Case rate,100% of Medicare MS-DRG,8145.79,100,CUSTOM-DRG,6516.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8145.79,100,CUSTOM-DRG,6516.63,Case rate,100% of GA Medicaid ,8145.79,15103.68,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7944.12,100,CUSTOM-DRG,6355.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9205.2,102,MS-DRG,7364.16,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7944.12,100,CUSTOM-DRG,6355.3,Case rate,100% of GA Medicaid ,9024.71,100,MS-DRG,7219.77,Case rate,100% of Medicare MS-DRG,7944.12,100,CUSTOM-DRG,6355.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7944.12,100,CUSTOM-DRG,6355.3,Case rate,100% of GA Medicaid ,7944.12,9205.2,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3495.88,100,CUSTOM-DRG,2796.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7101.14,102,MS-DRG,5680.91,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3495.88,100,CUSTOM-DRG,2796.7,Case rate,100% of GA Medicaid ,6961.9,100,MS-DRG,5569.52,Case rate,100% of Medicare MS-DRG,3495.88,100,CUSTOM-DRG,2796.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3495.88,100,CUSTOM-DRG,2796.7,Case rate,100% of GA Medicaid ,3495.88,7101.14,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12581.84,100,CUSTOM-DRG,10065.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20648.4,102,MS-DRG,16518.72,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12581.84,100,CUSTOM-DRG,10065.47,Case rate,100% of GA Medicaid ,20243.53,100,MS-DRG,16194.82,Case rate,100% of Medicare MS-DRG,12581.84,100,CUSTOM-DRG,10065.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12581.84,100,CUSTOM-DRG,10065.47,Case rate,100% of GA Medicaid ,12581.84,20648.4,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6585.66,100,CUSTOM-DRG,5268.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9932.46,102,MS-DRG,7945.97,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6585.66,100,CUSTOM-DRG,5268.53,Case rate,100% of GA Medicaid ,9737.71,100,MS-DRG,7790.17,Case rate,100% of Medicare MS-DRG,6585.66,100,CUSTOM-DRG,5268.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6585.66,100,CUSTOM-DRG,5268.53,Case rate,100% of GA Medicaid ,6585.66,9932.46,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4444.36,100,CUSTOM-DRG,3555.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7464.39,102,MS-DRG,5971.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4444.36,100,CUSTOM-DRG,3555.49,Case rate,100% of GA Medicaid ,7318.03,100,MS-DRG,5854.42,Case rate,100% of Medicare MS-DRG,4444.36,100,CUSTOM-DRG,3555.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4444.36,100,CUSTOM-DRG,3555.49,Case rate,100% of GA Medicaid ,4444.36,7464.39,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16148.03,102,MS-DRG,12918.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,15831.4,100,MS-DRG,12665.12,Case rate,100% of Medicare MS-DRG,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,7426.66,16148.03,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9989.6,102,MS-DRG,7991.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,9793.73,100,MS-DRG,7834.98,Case rate,100% of Medicare MS-DRG,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7426.66,100,CUSTOM-DRG,5941.33,Case rate,100% of GA Medicaid ,7426.66,9989.6,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4191.18,100,CUSTOM-DRG,3352.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8246.91,102,MS-DRG,6597.53,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4191.18,100,CUSTOM-DRG,3352.94,Case rate,100% of GA Medicaid ,8085.21,100,MS-DRG,6468.17,Case rate,100% of Medicare MS-DRG,4191.18,100,CUSTOM-DRG,3352.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4191.18,100,CUSTOM-DRG,3352.94,Case rate,100% of GA Medicaid ,4191.18,8246.91,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6144.66,100,CUSTOM-DRG,4915.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14094.95,102,MS-DRG,11275.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6144.66,100,CUSTOM-DRG,4915.73,Case rate,100% of GA Medicaid ,13818.58,100,MS-DRG,11054.86,Case rate,100% of Medicare MS-DRG,6144.66,100,CUSTOM-DRG,4915.73,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6144.66,100,CUSTOM-DRG,4915.73,Case rate,100% of GA Medicaid ,6144.66,14094.95,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4996.17,100,CUSTOM-DRG,3996.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8395.35,102,MS-DRG,6716.28,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4996.17,100,CUSTOM-DRG,3996.94,Case rate,100% of GA Medicaid ,8230.74,100,MS-DRG,6584.59,Case rate,100% of Medicare MS-DRG,4996.17,100,CUSTOM-DRG,3996.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4996.17,100,CUSTOM-DRG,3996.94,Case rate,100% of GA Medicaid ,4996.17,8395.35,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4715.28,100,CUSTOM-DRG,3772.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11192.98,102,MS-DRG,8954.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4715.28,100,CUSTOM-DRG,3772.22,Case rate,100% of GA Medicaid ,10973.51,100,MS-DRG,8778.81,Case rate,100% of Medicare MS-DRG,4715.28,100,CUSTOM-DRG,3772.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4715.28,100,CUSTOM-DRG,3772.22,Case rate,100% of GA Medicaid ,4715.28,11192.98,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4414.45,100,CUSTOM-DRG,3531.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7454.64,102,MS-DRG,5963.71,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4414.45,100,CUSTOM-DRG,3531.56,Case rate,100% of GA Medicaid ,7308.47,100,MS-DRG,5846.78,Case rate,100% of Medicare MS-DRG,4414.45,100,CUSTOM-DRG,3531.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4414.45,100,CUSTOM-DRG,3531.56,Case rate,100% of GA Medicaid ,4414.45,7454.64,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6332.47,100,CUSTOM-DRG,5065.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11586.36,102,MS-DRG,9269.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6332.47,100,CUSTOM-DRG,5065.98,Case rate,100% of GA Medicaid ,11359.18,100,MS-DRG,9087.34,Case rate,100% of Medicare MS-DRG,6332.47,100,CUSTOM-DRG,5065.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6332.47,100,CUSTOM-DRG,5065.98,Case rate,100% of GA Medicaid ,6332.47,11586.36,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4191.73,100,CUSTOM-DRG,3353.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7471.55,102,MS-DRG,5977.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4191.73,100,CUSTOM-DRG,3353.38,Case rate,100% of GA Medicaid ,7325.05,100,MS-DRG,5860.04,Case rate,100% of Medicare MS-DRG,4191.73,100,CUSTOM-DRG,3353.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4191.73,100,CUSTOM-DRG,3353.38,Case rate,100% of GA Medicaid ,4191.73,7471.55,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5495.34,100,CUSTOM-DRG,4396.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12893.25,102,MS-DRG,10314.6,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5495.34,100,CUSTOM-DRG,4396.27,Case rate,100% of GA Medicaid ,12640.44,100,MS-DRG,10112.35,Case rate,100% of Medicare MS-DRG,5495.34,100,CUSTOM-DRG,4396.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5495.34,100,CUSTOM-DRG,4396.27,Case rate,100% of GA Medicaid ,5495.34,12893.25,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4318.05,100,CUSTOM-DRG,3454.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7823.1,102,MS-DRG,6258.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4318.05,100,CUSTOM-DRG,3454.44,Case rate,100% of GA Medicaid ,7669.71,100,MS-DRG,6135.77,Case rate,100% of Medicare MS-DRG,4318.05,100,CUSTOM-DRG,3454.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4318.05,100,CUSTOM-DRG,3454.44,Case rate,100% of GA Medicaid ,4318.05,7823.1,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16046.14,100,CUSTOM-DRG,12836.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15325.63,102,MS-DRG,12260.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16046.14,100,CUSTOM-DRG,12836.91,Case rate,100% of GA Medicaid ,15025.13,100,MS-DRG,12020.1,Case rate,100% of Medicare MS-DRG,16046.14,100,CUSTOM-DRG,12836.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16046.14,100,CUSTOM-DRG,12836.91,Case rate,100% of GA Medicaid ,15025.13,16046.14,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11229.47,100,CUSTOM-DRG,8983.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9474.73,102,MS-DRG,7579.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11229.47,100,CUSTOM-DRG,8983.58,Case rate,100% of GA Medicaid ,9288.95,100,MS-DRG,7431.16,Case rate,100% of Medicare MS-DRG,11229.47,100,CUSTOM-DRG,8983.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11229.47,100,CUSTOM-DRG,8983.58,Case rate,100% of GA Medicaid ,9288.95,11229.47,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8304.24,100,CUSTOM-DRG,6643.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7183.81,102,MS-DRG,5747.05,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8304.24,100,CUSTOM-DRG,6643.39,Case rate,100% of GA Medicaid ,7042.95,100,MS-DRG,5634.36,Case rate,100% of Medicare MS-DRG,8304.24,100,CUSTOM-DRG,6643.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8304.24,100,CUSTOM-DRG,6643.39,Case rate,100% of GA Medicaid ,7042.95,8304.24,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5362.38,100,CUSTOM-DRG,4289.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12594.27,102,MS-DRG,10075.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5362.38,100,CUSTOM-DRG,4289.9,Case rate,100% of GA Medicaid ,12347.32,100,MS-DRG,9877.86,Case rate,100% of Medicare MS-DRG,5362.38,100,CUSTOM-DRG,4289.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5362.38,100,CUSTOM-DRG,4289.9,Case rate,100% of GA Medicaid ,5362.38,12594.27,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4745.2,100,CUSTOM-DRG,3796.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7935.07,102,MS-DRG,6348.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4745.2,100,CUSTOM-DRG,3796.16,Case rate,100% of GA Medicaid ,7779.48,100,MS-DRG,6223.58,Case rate,100% of Medicare MS-DRG,4745.2,100,CUSTOM-DRG,3796.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4745.2,100,CUSTOM-DRG,3796.16,Case rate,100% of GA Medicaid ,4745.2,7935.07,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12935.48,102,MS-DRG,10348.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,12681.84,100,MS-DRG,10145.47,Case rate,100% of Medicare MS-DRG,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,6283.16,12935.48,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8610.83,102,MS-DRG,6888.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,8441.99,100,MS-DRG,6753.59,Case rate,100% of Medicare MS-DRG,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6283.16,100,CUSTOM-DRG,5026.53,Case rate,100% of GA Medicaid ,6283.16,8610.83,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3216.65,100,CUSTOM-DRG,2573.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6990.45,102,MS-DRG,5592.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3216.65,100,CUSTOM-DRG,2573.32,Case rate,100% of GA Medicaid ,6853.38,100,MS-DRG,5482.7,Case rate,100% of Medicare MS-DRG,3216.65,100,CUSTOM-DRG,2573.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3216.65,100,CUSTOM-DRG,2573.32,Case rate,100% of GA Medicaid ,3216.65,6990.45,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9084.3,100,CUSTOM-DRG,7267.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24201.34,102,MS-DRG,19361.07,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9084.3,100,CUSTOM-DRG,7267.44,Case rate,100% of GA Medicaid ,23726.8,100,MS-DRG,18981.44,Case rate,100% of Medicare MS-DRG,9084.3,100,CUSTOM-DRG,7267.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9084.3,100,CUSTOM-DRG,7267.44,Case rate,100% of GA Medicaid ,9084.3,24201.34,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6750.76,100,CUSTOM-DRG,5400.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14012.13,102,MS-DRG,11209.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6750.76,100,CUSTOM-DRG,5400.61,Case rate,100% of GA Medicaid ,13737.38,100,MS-DRG,10989.9,Case rate,100% of Medicare MS-DRG,6750.76,100,CUSTOM-DRG,5400.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6750.76,100,CUSTOM-DRG,5400.61,Case rate,100% of GA Medicaid ,6750.76,14012.13,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5033.84,100,CUSTOM-DRG,4027.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9523.57,102,MS-DRG,7618.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5033.84,100,CUSTOM-DRG,4027.07,Case rate,100% of GA Medicaid ,9336.83,100,MS-DRG,7469.46,Case rate,100% of Medicare MS-DRG,5033.84,100,CUSTOM-DRG,4027.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5033.84,100,CUSTOM-DRG,4027.07,Case rate,100% of GA Medicaid ,5033.84,9523.57,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15358.6,100,CUSTOM-DRG,12286.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,51497.62,102,MS-DRG,41198.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15358.6,100,CUSTOM-DRG,12286.88,Case rate,100% of GA Medicaid ,50487.86,100,MS-DRG,40390.29,Case rate,100% of Medicare MS-DRG,15358.6,100,CUSTOM-DRG,12286.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15358.6,100,CUSTOM-DRG,12286.88,Case rate,100% of GA Medicaid ,15358.6,51497.62,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12095.96,100,CUSTOM-DRG,9676.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28206.46,102,MS-DRG,22565.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12095.96,100,CUSTOM-DRG,9676.77,Case rate,100% of GA Medicaid ,27653.39,100,MS-DRG,22122.71,Case rate,100% of Medicare MS-DRG,12095.96,100,CUSTOM-DRG,9676.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12095.96,100,CUSTOM-DRG,9676.77,Case rate,100% of GA Medicaid ,12095.96,28206.46,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7945.23,100,CUSTOM-DRG,6356.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16944.74,102,MS-DRG,13555.79,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7945.23,100,CUSTOM-DRG,6356.18,Case rate,100% of GA Medicaid ,16612.49,100,MS-DRG,13289.99,Case rate,100% of Medicare MS-DRG,7945.23,100,CUSTOM-DRG,6356.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7945.23,100,CUSTOM-DRG,6356.18,Case rate,100% of GA Medicaid ,7945.23,16944.74,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28265.09,100,CUSTOM-DRG,22612.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,47066.8,102,MS-DRG,37653.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,28265.09,100,CUSTOM-DRG,22612.07,Case rate,100% of GA Medicaid ,46143.92,100,MS-DRG,36915.14,Case rate,100% of Medicare MS-DRG,28265.09,100,CUSTOM-DRG,22612.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28265.09,100,CUSTOM-DRG,22612.07,Case rate,100% of GA Medicaid ,28265.09,47066.8,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12595.69,100,CUSTOM-DRG,10076.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21939.55,102,MS-DRG,17551.64,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12595.69,100,CUSTOM-DRG,10076.55,Case rate,100% of GA Medicaid ,21509.36,100,MS-DRG,17207.49,Case rate,100% of Medicare MS-DRG,12595.69,100,CUSTOM-DRG,10076.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12595.69,100,CUSTOM-DRG,10076.55,Case rate,100% of GA Medicaid ,12595.69,21939.55,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8306.45,100,CUSTOM-DRG,6645.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13337.98,102,MS-DRG,10670.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8306.45,100,CUSTOM-DRG,6645.16,Case rate,100% of GA Medicaid ,13076.45,100,MS-DRG,10461.16,Case rate,100% of Medicare MS-DRG,8306.45,100,CUSTOM-DRG,6645.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8306.45,100,CUSTOM-DRG,6645.16,Case rate,100% of GA Medicaid ,8306.45,13337.98,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16981.88,100,CUSTOM-DRG,13585.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27679.73,102,MS-DRG,22143.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16981.88,100,CUSTOM-DRG,13585.5,Case rate,100% of GA Medicaid ,27136.99,100,MS-DRG,21709.59,Case rate,100% of Medicare MS-DRG,16981.88,100,CUSTOM-DRG,13585.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16981.88,100,CUSTOM-DRG,13585.5,Case rate,100% of GA Medicaid ,16981.88,27679.73,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7639.96,100,CUSTOM-DRG,6111.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14465.15,102,MS-DRG,11572.12,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7639.96,100,CUSTOM-DRG,6111.97,Case rate,100% of GA Medicaid ,14181.52,100,MS-DRG,11345.22,Case rate,100% of Medicare MS-DRG,7639.96,100,CUSTOM-DRG,6111.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7639.96,100,CUSTOM-DRG,6111.97,Case rate,100% of GA Medicaid ,7639.96,14465.15,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5448.81,100,CUSTOM-DRG,4359.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11153.22,102,MS-DRG,8922.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5448.81,100,CUSTOM-DRG,4359.05,Case rate,100% of GA Medicaid ,10934.53,100,MS-DRG,8747.62,Case rate,100% of Medicare MS-DRG,5448.81,100,CUSTOM-DRG,4359.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5448.81,100,CUSTOM-DRG,4359.05,Case rate,100% of GA Medicaid ,5448.81,11153.22,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8514.76,100,CUSTOM-DRG,6811.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14421.26,102,MS-DRG,11537.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8514.76,100,CUSTOM-DRG,6811.81,Case rate,100% of GA Medicaid ,14138.49,100,MS-DRG,11310.79,Case rate,100% of Medicare MS-DRG,8514.76,100,CUSTOM-DRG,6811.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8514.76,100,CUSTOM-DRG,6811.81,Case rate,100% of GA Medicaid ,8514.76,14421.26,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7985.67,100,CUSTOM-DRG,6388.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12604.21,102,MS-DRG,10083.37,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7985.67,100,CUSTOM-DRG,6388.54,Case rate,100% of GA Medicaid ,12357.07,100,MS-DRG,9885.66,Case rate,100% of Medicare MS-DRG,7985.67,100,CUSTOM-DRG,6388.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7985.67,100,CUSTOM-DRG,6388.54,Case rate,100% of GA Medicaid ,7985.67,12604.21,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9480.98,100,CUSTOM-DRG,7584.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16220.91,102,MS-DRG,12976.73,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9480.98,100,CUSTOM-DRG,7584.78,Case rate,100% of GA Medicaid ,15902.85,100,MS-DRG,12722.28,Case rate,100% of Medicare MS-DRG,9480.98,100,CUSTOM-DRG,7584.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9480.98,100,CUSTOM-DRG,7584.78,Case rate,100% of GA Medicaid ,9480.98,16220.91,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8502.58,100,CUSTOM-DRG,6802.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13946.69,102,MS-DRG,11157.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8502.58,100,CUSTOM-DRG,6802.06,Case rate,100% of GA Medicaid ,13673.23,100,MS-DRG,10938.58,Case rate,100% of Medicare MS-DRG,8502.58,100,CUSTOM-DRG,6802.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8502.58,100,CUSTOM-DRG,6802.06,Case rate,100% of GA Medicaid ,8502.58,13946.69,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7994.54,100,CUSTOM-DRG,6395.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17309.98,102,MS-DRG,13847.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7994.54,100,CUSTOM-DRG,6395.63,Case rate,100% of GA Medicaid ,16970.57,100,MS-DRG,13576.46,Case rate,100% of Medicare MS-DRG,7994.54,100,CUSTOM-DRG,6395.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7994.54,100,CUSTOM-DRG,6395.63,Case rate,100% of GA Medicaid ,7994.54,17309.98,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5620.55,100,CUSTOM-DRG,4496.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10020.26,102,MS-DRG,8016.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5620.55,100,CUSTOM-DRG,4496.44,Case rate,100% of GA Medicaid ,9823.78,100,MS-DRG,7859.02,Case rate,100% of Medicare MS-DRG,5620.55,100,CUSTOM-DRG,4496.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5620.55,100,CUSTOM-DRG,4496.44,Case rate,100% of GA Medicaid ,5620.55,10020.26,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2786.73,100,CUSTOM-DRG,2229.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7230.68,102,MS-DRG,5784.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2786.73,100,CUSTOM-DRG,2229.38,Case rate,100% of GA Medicaid ,7088.9,100,MS-DRG,5671.12,Case rate,100% of Medicare MS-DRG,2786.73,100,CUSTOM-DRG,2229.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2786.73,100,CUSTOM-DRG,2229.38,Case rate,100% of GA Medicaid ,2786.73,7230.68,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8244.4,100,CUSTOM-DRG,6595.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18013.11,102,MS-DRG,14410.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8244.4,100,CUSTOM-DRG,6595.52,Case rate,100% of GA Medicaid ,17659.91,100,MS-DRG,14127.93,Case rate,100% of Medicare MS-DRG,8244.4,100,CUSTOM-DRG,6595.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8244.4,100,CUSTOM-DRG,6595.52,Case rate,100% of GA Medicaid ,8244.4,18013.11,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8673.34,102,MS-DRG,6938.67,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,8503.27,100,MS-DRG,6802.62,Case rate,100% of Medicare MS-DRG,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4975.12,100,CUSTOM-DRG,3980.1,Case rate,100% of GA Medicaid ,4975.12,8673.34,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6805.61,100,CUSTOM-DRG,5444.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13255.17,102,MS-DRG,10604.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6805.61,100,CUSTOM-DRG,5444.49,Case rate,100% of GA Medicaid ,12995.26,100,MS-DRG,10396.21,Case rate,100% of Medicare MS-DRG,6805.61,100,CUSTOM-DRG,5444.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6805.61,100,CUSTOM-DRG,5444.49,Case rate,100% of GA Medicaid ,6805.61,13255.17,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9928.32,102,MS-DRG,7942.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,9733.65,100,MS-DRG,7786.92,Case rate,100% of Medicare MS-DRG,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,5149.08,9928.32,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6484.63,102,MS-DRG,5187.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,6357.48,100,MS-DRG,5085.98,Case rate,100% of Medicare MS-DRG,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5149.08,100,CUSTOM-DRG,4119.26,Case rate,100% of GA Medicaid ,5149.08,6484.63,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5095.34,100,CUSTOM-DRG,4076.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8780.74,102,MS-DRG,7024.59,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5095.34,100,CUSTOM-DRG,4076.27,Case rate,100% of GA Medicaid ,8608.57,100,MS-DRG,6886.86,Case rate,100% of Medicare MS-DRG,5095.34,100,CUSTOM-DRG,4076.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5095.34,100,CUSTOM-DRG,4076.27,Case rate,100% of GA Medicaid ,5095.34,8780.74,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3809.46,100,CUSTOM-DRG,3047.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6228.76,102,MS-DRG,4983.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3809.46,100,CUSTOM-DRG,3047.57,Case rate,100% of GA Medicaid ,6106.63,100,MS-DRG,4885.3,Case rate,100% of Medicare MS-DRG,3809.46,100,CUSTOM-DRG,3047.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3809.46,100,CUSTOM-DRG,3047.57,Case rate,100% of GA Medicaid ,3809.46,6228.76,
CELLULITIS WITH MCC,602,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7566.28,100,CUSTOM-DRG,6053.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12319.33,102,MS-DRG,9855.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7566.28,100,CUSTOM-DRG,6053.02,Case rate,100% of GA Medicaid ,12077.77,100,MS-DRG,9662.22,Case rate,100% of Medicare MS-DRG,7566.28,100,CUSTOM-DRG,6053.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7566.28,100,CUSTOM-DRG,6053.02,Case rate,100% of GA Medicaid ,7566.28,12319.33,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4894.78,100,CUSTOM-DRG,3915.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7864.13,102,MS-DRG,6291.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4894.78,100,CUSTOM-DRG,3915.82,Case rate,100% of GA Medicaid ,7709.93,100,MS-DRG,6167.94,Case rate,100% of Medicare MS-DRG,4894.78,100,CUSTOM-DRG,3915.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4894.78,100,CUSTOM-DRG,3915.82,Case rate,100% of GA Medicaid ,4894.78,7864.13,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5386.2,100,CUSTOM-DRG,4308.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12474.18,102,MS-DRG,9979.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5386.2,100,CUSTOM-DRG,4308.96,Case rate,100% of GA Medicaid ,12229.59,100,MS-DRG,9783.67,Case rate,100% of Medicare MS-DRG,5386.2,100,CUSTOM-DRG,4308.96,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5386.2,100,CUSTOM-DRG,4308.96,Case rate,100% of GA Medicaid ,5386.2,12474.18,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8021.03,102,MS-DRG,6416.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,7863.75,100,MS-DRG,6291,Case rate,100% of Medicare MS-DRG,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3864.3,100,CUSTOM-DRG,3091.44,Case rate,100% of GA Medicaid ,3864.3,8021.03,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5066.53,100,CUSTOM-DRG,4053.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13133.42,102,MS-DRG,10506.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5066.53,100,CUSTOM-DRG,4053.22,Case rate,100% of GA Medicaid ,12875.9,100,MS-DRG,10300.72,Case rate,100% of Medicare MS-DRG,5066.53,100,CUSTOM-DRG,4053.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5066.53,100,CUSTOM-DRG,4053.22,Case rate,100% of GA Medicaid ,5066.53,13133.42,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3839.93,100,CUSTOM-DRG,3071.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7921.41,102,MS-DRG,6337.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3839.93,100,CUSTOM-DRG,3071.94,Case rate,100% of GA Medicaid ,7766.09,100,MS-DRG,6212.87,Case rate,100% of Medicare MS-DRG,3839.93,100,CUSTOM-DRG,3071.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3839.93,100,CUSTOM-DRG,3071.94,Case rate,100% of GA Medicaid ,3839.93,7921.41,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14439.48,100,CUSTOM-DRG,11551.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18654.13,102,MS-DRG,14923.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14439.48,100,CUSTOM-DRG,11551.58,Case rate,100% of GA Medicaid ,18288.36,100,MS-DRG,14630.69,Case rate,100% of Medicare MS-DRG,14439.48,100,CUSTOM-DRG,11551.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14439.48,100,CUSTOM-DRG,11551.58,Case rate,100% of GA Medicaid ,14439.48,18654.13,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7103.12,100,CUSTOM-DRG,5682.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12183.49,102,MS-DRG,9746.79,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7103.12,100,CUSTOM-DRG,5682.5,Case rate,100% of GA Medicaid ,11944.6,100,MS-DRG,9555.68,Case rate,100% of Medicare MS-DRG,7103.12,100,CUSTOM-DRG,5682.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7103.12,100,CUSTOM-DRG,5682.5,Case rate,100% of GA Medicaid ,7103.12,12183.49,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17979.68,100,CUSTOM-DRG,14383.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32777.23,102,MS-DRG,26221.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17979.68,100,CUSTOM-DRG,14383.74,Case rate,100% of GA Medicaid ,32134.54,100,MS-DRG,25707.63,Case rate,100% of Medicare MS-DRG,17979.68,100,CUSTOM-DRG,14383.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17979.68,100,CUSTOM-DRG,14383.74,Case rate,100% of GA Medicaid ,17979.68,32777.23,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10395.67,100,CUSTOM-DRG,8316.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16435.41,102,MS-DRG,13148.33,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10395.67,100,CUSTOM-DRG,8316.54,Case rate,100% of GA Medicaid ,16113.15,100,MS-DRG,12890.52,Case rate,100% of Medicare MS-DRG,10395.67,100,CUSTOM-DRG,8316.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10395.67,100,CUSTOM-DRG,8316.54,Case rate,100% of GA Medicaid ,10395.67,16435.41,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7350.21,100,CUSTOM-DRG,5880.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9666.13,102,MS-DRG,7732.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7350.21,100,CUSTOM-DRG,5880.17,Case rate,100% of GA Medicaid ,9476.6,100,MS-DRG,7581.28,Case rate,100% of Medicare MS-DRG,7350.21,100,CUSTOM-DRG,5880.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7350.21,100,CUSTOM-DRG,5880.17,Case rate,100% of GA Medicaid ,7350.21,9666.13,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15212.89,100,CUSTOM-DRG,12170.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21553.61,102,MS-DRG,17242.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15212.89,100,CUSTOM-DRG,12170.31,Case rate,100% of GA Medicaid ,21130.99,100,MS-DRG,16904.79,Case rate,100% of Medicare MS-DRG,15212.89,100,CUSTOM-DRG,12170.31,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15212.89,100,CUSTOM-DRG,12170.31,Case rate,100% of GA Medicaid ,15212.89,21553.61,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9782.92,100,CUSTOM-DRG,7826.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13434.88,102,MS-DRG,10747.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9782.92,100,CUSTOM-DRG,7826.34,Case rate,100% of GA Medicaid ,13171.45,100,MS-DRG,10537.16,Case rate,100% of Medicare MS-DRG,9782.92,100,CUSTOM-DRG,7826.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9782.92,100,CUSTOM-DRG,7826.34,Case rate,100% of GA Medicaid ,9782.92,13434.88,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7869.88,100,CUSTOM-DRG,6295.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12566.11,102,MS-DRG,10052.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7869.88,100,CUSTOM-DRG,6295.9,Case rate,100% of GA Medicaid ,12319.72,100,MS-DRG,9855.78,Case rate,100% of Medicare MS-DRG,7869.88,100,CUSTOM-DRG,6295.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7869.88,100,CUSTOM-DRG,6295.9,Case rate,100% of GA Medicaid ,7869.88,12566.11,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18338.68,100,CUSTOM-DRG,14670.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,31683.2,102,MS-DRG,25346.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,18338.68,100,CUSTOM-DRG,14670.94,Case rate,100% of GA Medicaid ,31061.96,100,MS-DRG,24849.57,Case rate,100% of Medicare MS-DRG,18338.68,100,CUSTOM-DRG,14670.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18338.68,100,CUSTOM-DRG,14670.94,Case rate,100% of GA Medicaid ,18338.68,31683.2,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10018.38,100,CUSTOM-DRG,8014.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15415.91,102,MS-DRG,12332.73,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10018.38,100,CUSTOM-DRG,8014.7,Case rate,100% of GA Medicaid ,15113.64,100,MS-DRG,12090.91,Case rate,100% of Medicare MS-DRG,10018.38,100,CUSTOM-DRG,8014.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10018.38,100,CUSTOM-DRG,8014.7,Case rate,100% of GA Medicaid ,10018.38,15415.91,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4019.43,100,CUSTOM-DRG,3215.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9360.14,102,MS-DRG,7488.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4019.43,100,CUSTOM-DRG,3215.54,Case rate,100% of GA Medicaid ,9176.61,100,MS-DRG,7341.29,Case rate,100% of Medicare MS-DRG,4019.43,100,CUSTOM-DRG,3215.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4019.43,100,CUSTOM-DRG,3215.54,Case rate,100% of GA Medicaid ,4019.43,9360.14,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10429.46,100,CUSTOM-DRG,8343.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24193.05,102,MS-DRG,19354.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10429.46,100,CUSTOM-DRG,8343.57,Case rate,100% of GA Medicaid ,23718.68,100,MS-DRG,18974.94,Case rate,100% of Medicare MS-DRG,10429.46,100,CUSTOM-DRG,8343.57,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10429.46,100,CUSTOM-DRG,8343.57,Case rate,100% of GA Medicaid ,10429.46,24193.05,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8816.15,100,CUSTOM-DRG,7052.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12355.75,102,MS-DRG,9884.6,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8816.15,100,CUSTOM-DRG,7052.92,Case rate,100% of GA Medicaid ,12113.48,100,MS-DRG,9690.78,Case rate,100% of Medicare MS-DRG,8816.15,100,CUSTOM-DRG,7052.92,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8816.15,100,CUSTOM-DRG,7052.92,Case rate,100% of GA Medicaid ,8816.15,12355.75,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6421.11,100,CUSTOM-DRG,5136.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10236.41,102,MS-DRG,8189.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6421.11,100,CUSTOM-DRG,5136.89,Case rate,100% of GA Medicaid ,10035.7,100,MS-DRG,8028.56,Case rate,100% of Medicare MS-DRG,6421.11,100,CUSTOM-DRG,5136.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6421.11,100,CUSTOM-DRG,5136.89,Case rate,100% of GA Medicaid ,6421.11,10236.41,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,33247.63,102,MS-DRG,26598.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,32595.72,100,MS-DRG,26076.58,Case rate,100% of Medicare MS-DRG,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,13393.48,33247.63,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18740.27,102,MS-DRG,14992.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,18372.81,100,MS-DRG,14698.25,Case rate,100% of Medicare MS-DRG,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13393.48,100,CUSTOM-DRG,10714.78,Case rate,100% of GA Medicaid ,13393.48,18740.27,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6639.4,100,CUSTOM-DRG,5311.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11564.01,102,MS-DRG,9251.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6639.4,100,CUSTOM-DRG,5311.52,Case rate,100% of GA Medicaid ,11337.26,100,MS-DRG,9069.81,Case rate,100% of Medicare MS-DRG,6639.4,100,CUSTOM-DRG,5311.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6639.4,100,CUSTOM-DRG,5311.52,Case rate,100% of GA Medicaid ,6639.4,11564.01,
DIABETES WITH MCC,637,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7483.18,100,CUSTOM-DRG,5986.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12002.94,102,MS-DRG,9602.35,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7483.18,100,CUSTOM-DRG,5986.54,Case rate,100% of GA Medicaid ,11767.59,100,MS-DRG,9414.07,Case rate,100% of Medicare MS-DRG,7483.18,100,CUSTOM-DRG,5986.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7483.18,100,CUSTOM-DRG,5986.54,Case rate,100% of GA Medicaid ,7483.18,12002.94,
DIABETES WITH CC,638,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4367.36,100,CUSTOM-DRG,3493.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7959.83,102,MS-DRG,6367.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4367.36,100,CUSTOM-DRG,3493.89,Case rate,100% of GA Medicaid ,7803.75,100,MS-DRG,6243,Case rate,100% of Medicare MS-DRG,4367.36,100,CUSTOM-DRG,3493.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4367.36,100,CUSTOM-DRG,3493.89,Case rate,100% of GA Medicaid ,4367.36,7959.83,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3041.58,100,CUSTOM-DRG,2433.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6157.16,102,MS-DRG,4925.73,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3041.58,100,CUSTOM-DRG,2433.26,Case rate,100% of GA Medicaid ,6036.43,100,MS-DRG,4829.14,Case rate,100% of Medicare MS-DRG,3041.58,100,CUSTOM-DRG,2433.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3041.58,100,CUSTOM-DRG,2433.26,Case rate,100% of GA Medicaid ,3041.58,6157.16,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5373.46,100,CUSTOM-DRG,4298.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10892.34,102,MS-DRG,8713.87,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5373.46,100,CUSTOM-DRG,4298.77,Case rate,100% of GA Medicaid ,10678.76,100,MS-DRG,8543.01,Case rate,100% of Medicare MS-DRG,5373.46,100,CUSTOM-DRG,4298.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5373.46,100,CUSTOM-DRG,4298.77,Case rate,100% of GA Medicaid ,5373.46,10892.34,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4115.28,100,CUSTOM-DRG,3292.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7191.62,102,MS-DRG,5753.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4115.28,100,CUSTOM-DRG,3292.22,Case rate,100% of GA Medicaid ,7050.61,100,MS-DRG,5640.49,Case rate,100% of Medicare MS-DRG,4115.28,100,CUSTOM-DRG,3292.22,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4115.28,100,CUSTOM-DRG,3292.22,Case rate,100% of GA Medicaid ,4115.28,7191.62,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5093.12,100,CUSTOM-DRG,4074.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10793.79,102,MS-DRG,8635.03,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5093.12,100,CUSTOM-DRG,4074.5,Case rate,100% of GA Medicaid ,10582.15,100,MS-DRG,8465.72,Case rate,100% of Medicare MS-DRG,5093.12,100,CUSTOM-DRG,4074.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5093.12,100,CUSTOM-DRG,4074.5,Case rate,100% of GA Medicaid ,5093.12,10793.79,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9442.75,100,CUSTOM-DRG,7554.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13624.54,102,MS-DRG,10899.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9442.75,100,CUSTOM-DRG,7554.2,Case rate,100% of GA Medicaid ,13357.39,100,MS-DRG,10685.91,Case rate,100% of Medicare MS-DRG,9442.75,100,CUSTOM-DRG,7554.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9442.75,100,CUSTOM-DRG,7554.2,Case rate,100% of GA Medicaid ,9442.75,13624.54,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5008.91,100,CUSTOM-DRG,4007.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9016.41,102,MS-DRG,7213.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5008.91,100,CUSTOM-DRG,4007.13,Case rate,100% of GA Medicaid ,8839.62,100,MS-DRG,7071.7,Case rate,100% of Medicare MS-DRG,5008.91,100,CUSTOM-DRG,4007.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5008.91,100,CUSTOM-DRG,4007.13,Case rate,100% of GA Medicaid ,5008.91,9016.41,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3851.01,100,CUSTOM-DRG,3080.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7058.17,102,MS-DRG,5646.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3851.01,100,CUSTOM-DRG,3080.81,Case rate,100% of GA Medicaid ,6919.77,100,MS-DRG,5535.82,Case rate,100% of Medicare MS-DRG,3851.01,100,CUSTOM-DRG,3080.81,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3851.01,100,CUSTOM-DRG,3080.81,Case rate,100% of GA Medicaid ,3851.01,7058.17,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8069.33,100,CUSTOM-DRG,6455.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,37247.8,102,MS-DRG,29798.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8069.33,100,CUSTOM-DRG,6455.46,Case rate,100% of GA Medicaid ,36517.45,100,MS-DRG,29213.96,Case rate,100% of Medicare MS-DRG,8069.33,100,CUSTOM-DRG,6455.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8069.33,100,CUSTOM-DRG,6455.46,Case rate,100% of GA Medicaid ,8069.33,37247.8,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,47634.81,100,CUSTOM-DRG,38107.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28642.08,102,MS-DRG,22913.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,47634.81,100,CUSTOM-DRG,38107.85,Case rate,100% of GA Medicaid ,28080.47,100,MS-DRG,22464.38,Case rate,100% of Medicare MS-DRG,47634.81,100,CUSTOM-DRG,38107.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,47634.81,100,CUSTOM-DRG,38107.85,Case rate,100% of GA Medicaid ,28080.47,47634.81,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,76531.49,100,CUSTOM-DRG,61225.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24882.1,102,MS-DRG,19905.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,76531.49,100,CUSTOM-DRG,61225.19,Case rate,100% of GA Medicaid ,24394.22,100,MS-DRG,19515.38,Case rate,100% of Medicare MS-DRG,76531.49,100,CUSTOM-DRG,61225.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,76531.49,100,CUSTOM-DRG,61225.19,Case rate,100% of GA Medicaid ,24394.22,76531.49,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26478.37,100,CUSTOM-DRG,21182.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,44834.82,102,MS-DRG,35867.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,26478.37,100,CUSTOM-DRG,21182.7,Case rate,100% of GA Medicaid ,43955.71,100,MS-DRG,35164.57,Case rate,100% of Medicare MS-DRG,26478.37,100,CUSTOM-DRG,21182.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26478.37,100,CUSTOM-DRG,21182.7,Case rate,100% of GA Medicaid ,26478.37,44834.82,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12129.2,100,CUSTOM-DRG,9703.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22671.66,102,MS-DRG,18137.33,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12129.2,100,CUSTOM-DRG,9703.36,Case rate,100% of GA Medicaid ,22227.12,100,MS-DRG,17781.7,Case rate,100% of Medicare MS-DRG,12129.2,100,CUSTOM-DRG,9703.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12129.2,100,CUSTOM-DRG,9703.36,Case rate,100% of GA Medicaid ,12129.2,22671.66,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9996.22,100,CUSTOM-DRG,7996.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17456.57,102,MS-DRG,13965.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9996.22,100,CUSTOM-DRG,7996.98,Case rate,100% of GA Medicaid ,17114.28,100,MS-DRG,13691.42,Case rate,100% of Medicare MS-DRG,9996.22,100,CUSTOM-DRG,7996.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9996.22,100,CUSTOM-DRG,7996.98,Case rate,100% of GA Medicaid ,9996.22,17456.57,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15078.82,100,CUSTOM-DRG,12063.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25985.25,102,MS-DRG,20788.2,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15078.82,100,CUSTOM-DRG,12063.06,Case rate,100% of GA Medicaid ,25475.74,100,MS-DRG,20380.59,Case rate,100% of Medicare MS-DRG,15078.82,100,CUSTOM-DRG,12063.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15078.82,100,CUSTOM-DRG,12063.06,Case rate,100% of GA Medicaid ,15078.82,25985.25,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13174.64,100,CUSTOM-DRG,10539.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15273.46,102,MS-DRG,12218.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13174.64,100,CUSTOM-DRG,10539.71,Case rate,100% of GA Medicaid ,14973.98,100,MS-DRG,11979.18,Case rate,100% of Medicare MS-DRG,13174.64,100,CUSTOM-DRG,10539.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13174.64,100,CUSTOM-DRG,10539.71,Case rate,100% of GA Medicaid ,13174.64,15273.46,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9849.96,100,CUSTOM-DRG,7879.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12260.5,102,MS-DRG,9808.4,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9849.96,100,CUSTOM-DRG,7879.97,Case rate,100% of GA Medicaid ,12020.1,100,MS-DRG,9616.08,Case rate,100% of Medicare MS-DRG,9849.96,100,CUSTOM-DRG,7879.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9849.96,100,CUSTOM-DRG,7879.97,Case rate,100% of GA Medicaid ,9849.96,12260.5,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13927.01,100,CUSTOM-DRG,11141.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21440.98,102,MS-DRG,17152.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13927.01,100,CUSTOM-DRG,11141.61,Case rate,100% of GA Medicaid ,21020.57,100,MS-DRG,16816.46,Case rate,100% of Medicare MS-DRG,13927.01,100,CUSTOM-DRG,11141.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13927.01,100,CUSTOM-DRG,11141.61,Case rate,100% of GA Medicaid ,13927.01,21440.98,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7608.94,100,CUSTOM-DRG,6087.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11146.59,102,MS-DRG,8917.27,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7608.94,100,CUSTOM-DRG,6087.15,Case rate,100% of GA Medicaid ,10928.03,100,MS-DRG,8742.42,Case rate,100% of Medicare MS-DRG,7608.94,100,CUSTOM-DRG,6087.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7608.94,100,CUSTOM-DRG,6087.15,Case rate,100% of GA Medicaid ,7608.94,11146.59,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6750.2,100,CUSTOM-DRG,5400.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8929.82,102,MS-DRG,7143.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6750.2,100,CUSTOM-DRG,5400.16,Case rate,100% of GA Medicaid ,8754.73,100,MS-DRG,7003.78,Case rate,100% of Medicare MS-DRG,6750.2,100,CUSTOM-DRG,5400.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6750.2,100,CUSTOM-DRG,5400.16,Case rate,100% of GA Medicaid ,6750.2,8929.82,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18995.2,100,CUSTOM-DRG,15196.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24818.33,102,MS-DRG,19854.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,18995.2,100,CUSTOM-DRG,15196.16,Case rate,100% of GA Medicaid ,24331.7,100,MS-DRG,19465.36,Case rate,100% of Medicare MS-DRG,18995.2,100,CUSTOM-DRG,15196.16,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18995.2,100,CUSTOM-DRG,15196.16,Case rate,100% of GA Medicaid ,18995.2,24818.33,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7331.93,100,CUSTOM-DRG,5865.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12083.29,102,MS-DRG,9666.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7331.93,100,CUSTOM-DRG,5865.54,Case rate,100% of GA Medicaid ,11846.36,100,MS-DRG,9477.09,Case rate,100% of Medicare MS-DRG,7331.93,100,CUSTOM-DRG,5865.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7331.93,100,CUSTOM-DRG,5865.54,Case rate,100% of GA Medicaid ,7331.93,12083.29,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5639.39,100,CUSTOM-DRG,4511.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9015.77,102,MS-DRG,7212.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5639.39,100,CUSTOM-DRG,4511.51,Case rate,100% of GA Medicaid ,8838.99,100,MS-DRG,7071.19,Case rate,100% of Medicare MS-DRG,5639.39,100,CUSTOM-DRG,4511.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5639.39,100,CUSTOM-DRG,4511.51,Case rate,100% of GA Medicaid ,5639.39,9015.77,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14414.54,100,CUSTOM-DRG,11531.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25583.59,102,MS-DRG,20466.87,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14414.54,100,CUSTOM-DRG,11531.63,Case rate,100% of GA Medicaid ,25081.95,100,MS-DRG,20065.56,Case rate,100% of Medicare MS-DRG,14414.54,100,CUSTOM-DRG,11531.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14414.54,100,CUSTOM-DRG,11531.63,Case rate,100% of GA Medicaid ,14414.54,25583.59,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9385.69,100,CUSTOM-DRG,7508.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14223.32,102,MS-DRG,11378.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9385.69,100,CUSTOM-DRG,7508.55,Case rate,100% of GA Medicaid ,13944.43,100,MS-DRG,11155.54,Case rate,100% of Medicare MS-DRG,9385.69,100,CUSTOM-DRG,7508.55,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9385.69,100,CUSTOM-DRG,7508.55,Case rate,100% of GA Medicaid ,9385.69,14223.32,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5514.18,100,CUSTOM-DRG,4411.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8937.64,102,MS-DRG,7150.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5514.18,100,CUSTOM-DRG,4411.34,Case rate,100% of GA Medicaid ,8762.39,100,MS-DRG,7009.91,Case rate,100% of Medicare MS-DRG,5514.18,100,CUSTOM-DRG,4411.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5514.18,100,CUSTOM-DRG,4411.34,Case rate,100% of GA Medicaid ,5514.18,8937.64,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13797.36,100,CUSTOM-DRG,11037.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23338.37,102,MS-DRG,18670.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13797.36,100,CUSTOM-DRG,11037.89,Case rate,100% of GA Medicaid ,22880.75,100,MS-DRG,18304.6,Case rate,100% of Medicare MS-DRG,13797.36,100,CUSTOM-DRG,11037.89,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13797.36,100,CUSTOM-DRG,11037.89,Case rate,100% of GA Medicaid ,13797.36,23338.37,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6342.44,100,CUSTOM-DRG,5073.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12709.38,102,MS-DRG,10167.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6342.44,100,CUSTOM-DRG,5073.95,Case rate,100% of GA Medicaid ,12460.18,100,MS-DRG,9968.14,Case rate,100% of Medicare MS-DRG,6342.44,100,CUSTOM-DRG,5073.95,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6342.44,100,CUSTOM-DRG,5073.95,Case rate,100% of GA Medicaid ,6342.44,12709.38,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4273.17,100,CUSTOM-DRG,3418.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8371.26,102,MS-DRG,6697.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4273.17,100,CUSTOM-DRG,3418.54,Case rate,100% of GA Medicaid ,8207.12,100,MS-DRG,6565.7,Case rate,100% of Medicare MS-DRG,4273.17,100,CUSTOM-DRG,3418.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4273.17,100,CUSTOM-DRG,3418.54,Case rate,100% of GA Medicaid ,4273.17,8371.26,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7618.91,100,CUSTOM-DRG,6095.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14177.78,102,MS-DRG,11342.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7618.91,100,CUSTOM-DRG,6095.13,Case rate,100% of GA Medicaid ,13899.78,100,MS-DRG,11119.82,Case rate,100% of Medicare MS-DRG,7618.91,100,CUSTOM-DRG,6095.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7618.91,100,CUSTOM-DRG,6095.13,Case rate,100% of GA Medicaid ,7618.91,14177.78,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6638.85,100,CUSTOM-DRG,5311.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8207.86,102,MS-DRG,6566.29,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6638.85,100,CUSTOM-DRG,5311.08,Case rate,100% of GA Medicaid ,8046.92,100,MS-DRG,6437.54,Case rate,100% of Medicare MS-DRG,6638.85,100,CUSTOM-DRG,5311.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6638.85,100,CUSTOM-DRG,5311.08,Case rate,100% of GA Medicaid ,6638.85,8207.86,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14716.49,100,CUSTOM-DRG,11773.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30626.43,102,MS-DRG,24501.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14716.49,100,CUSTOM-DRG,11773.19,Case rate,100% of GA Medicaid ,30025.91,100,MS-DRG,24020.73,Case rate,100% of Medicare MS-DRG,14716.49,100,CUSTOM-DRG,11773.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14716.49,100,CUSTOM-DRG,11773.19,Case rate,100% of GA Medicaid ,14716.49,30626.43,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14179.64,100,CUSTOM-DRG,11343.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19729.12,102,MS-DRG,15783.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14179.64,100,CUSTOM-DRG,11343.71,Case rate,100% of GA Medicaid ,19342.27,100,MS-DRG,15473.82,Case rate,100% of Medicare MS-DRG,14179.64,100,CUSTOM-DRG,11343.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14179.64,100,CUSTOM-DRG,11343.71,Case rate,100% of GA Medicaid ,14179.64,19729.12,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7244.39,100,CUSTOM-DRG,5795.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13139.21,102,MS-DRG,10511.37,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7244.39,100,CUSTOM-DRG,5795.51,Case rate,100% of GA Medicaid ,12881.58,100,MS-DRG,10305.26,Case rate,100% of Medicare MS-DRG,7244.39,100,CUSTOM-DRG,5795.51,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7244.39,100,CUSTOM-DRG,5795.51,Case rate,100% of GA Medicaid ,7244.39,13139.21,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7340.79,100,CUSTOM-DRG,5872.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12429.45,102,MS-DRG,9943.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7340.79,100,CUSTOM-DRG,5872.63,Case rate,100% of GA Medicaid ,12185.74,100,MS-DRG,9748.59,Case rate,100% of Medicare MS-DRG,7340.79,100,CUSTOM-DRG,5872.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7340.79,100,CUSTOM-DRG,5872.63,Case rate,100% of GA Medicaid ,7340.79,12429.45,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5176.78,100,CUSTOM-DRG,4141.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7968.93,102,MS-DRG,6375.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5176.78,100,CUSTOM-DRG,4141.42,Case rate,100% of GA Medicaid ,7812.68,100,MS-DRG,6250.14,Case rate,100% of Medicare MS-DRG,5176.78,100,CUSTOM-DRG,4141.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5176.78,100,CUSTOM-DRG,4141.42,Case rate,100% of GA Medicaid ,5176.78,7968.93,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3209.45,100,CUSTOM-DRG,2567.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6066.01,102,MS-DRG,4852.81,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3209.45,100,CUSTOM-DRG,2567.56,Case rate,100% of GA Medicaid ,5947.07,100,MS-DRG,4757.66,Case rate,100% of Medicare MS-DRG,3209.45,100,CUSTOM-DRG,2567.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3209.45,100,CUSTOM-DRG,2567.56,Case rate,100% of GA Medicaid ,3209.45,6066.01,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5755.18,100,CUSTOM-DRG,4604.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15233.71,102,MS-DRG,12186.97,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5755.18,100,CUSTOM-DRG,4604.14,Case rate,100% of GA Medicaid ,14935.01,100,MS-DRG,11948.01,Case rate,100% of Medicare MS-DRG,5755.18,100,CUSTOM-DRG,4604.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5755.18,100,CUSTOM-DRG,4604.14,Case rate,100% of GA Medicaid ,5755.18,15233.71,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4476.5,100,CUSTOM-DRG,3581.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8909.66,102,MS-DRG,7127.73,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4476.5,100,CUSTOM-DRG,3581.2,Case rate,100% of GA Medicaid ,8734.96,100,MS-DRG,6987.97,Case rate,100% of Medicare MS-DRG,4476.5,100,CUSTOM-DRG,3581.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4476.5,100,CUSTOM-DRG,3581.2,Case rate,100% of GA Medicaid ,4476.5,8909.66,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2913.05,100,CUSTOM-DRG,2330.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7188.37,102,MS-DRG,5750.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2913.05,100,CUSTOM-DRG,2330.44,Case rate,100% of GA Medicaid ,7047.42,100,MS-DRG,5637.94,Case rate,100% of Medicare MS-DRG,2913.05,100,CUSTOM-DRG,2330.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2913.05,100,CUSTOM-DRG,2330.44,Case rate,100% of GA Medicaid ,2913.05,7188.37,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6105.32,100,CUSTOM-DRG,4884.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9750.11,102,MS-DRG,7800.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6105.32,100,CUSTOM-DRG,4884.26,Case rate,100% of GA Medicaid ,9558.93,100,MS-DRG,7647.14,Case rate,100% of Medicare MS-DRG,6105.32,100,CUSTOM-DRG,4884.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6105.32,100,CUSTOM-DRG,4884.26,Case rate,100% of GA Medicaid ,6105.32,9750.11,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4325.25,100,CUSTOM-DRG,3460.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7357.63,102,MS-DRG,5886.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4325.25,100,CUSTOM-DRG,3460.2,Case rate,100% of GA Medicaid ,7213.36,100,MS-DRG,5770.69,Case rate,100% of Medicare MS-DRG,4325.25,100,CUSTOM-DRG,3460.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4325.25,100,CUSTOM-DRG,3460.2,Case rate,100% of GA Medicaid ,4325.25,7357.63,
URINARY STONES WITH MCC,693,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5297,100,CUSTOM-DRG,4237.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11729.64,102,MS-DRG,9383.71,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5297,100,CUSTOM-DRG,4237.6,Case rate,100% of GA Medicaid ,11499.65,100,MS-DRG,9199.72,Case rate,100% of Medicare MS-DRG,5297,100,CUSTOM-DRG,4237.6,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5297,100,CUSTOM-DRG,4237.6,Case rate,100% of GA Medicaid ,5297,11729.64,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4064.31,100,CUSTOM-DRG,3251.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7200.08,102,MS-DRG,5760.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4064.31,100,CUSTOM-DRG,3251.45,Case rate,100% of GA Medicaid ,7058.9,100,MS-DRG,5647.12,Case rate,100% of Medicare MS-DRG,4064.31,100,CUSTOM-DRG,3251.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4064.31,100,CUSTOM-DRG,3251.45,Case rate,100% of GA Medicaid ,4064.31,7200.08,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5344.1,100,CUSTOM-DRG,4275.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9905.14,102,MS-DRG,7924.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5344.1,100,CUSTOM-DRG,4275.28,Case rate,100% of GA Medicaid ,9710.92,100,MS-DRG,7768.74,Case rate,100% of Medicare MS-DRG,5344.1,100,CUSTOM-DRG,4275.28,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5344.1,100,CUSTOM-DRG,4275.28,Case rate,100% of GA Medicaid ,5344.1,9905.14,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2879.25,100,CUSTOM-DRG,2303.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6610.26,102,MS-DRG,5288.21,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2879.25,100,CUSTOM-DRG,2303.4,Case rate,100% of GA Medicaid ,6480.65,100,MS-DRG,5184.52,Case rate,100% of Medicare MS-DRG,2879.25,100,CUSTOM-DRG,2303.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2879.25,100,CUSTOM-DRG,2303.4,Case rate,100% of GA Medicaid ,2879.25,6610.26,
URETHRAL STRICTURE,697,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3370.67,100,CUSTOM-DRG,2696.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9351.03,102,MS-DRG,7480.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3370.67,100,CUSTOM-DRG,2696.54,Case rate,100% of GA Medicaid ,9167.68,100,MS-DRG,7334.14,Case rate,100% of Medicare MS-DRG,3370.67,100,CUSTOM-DRG,2696.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3370.67,100,CUSTOM-DRG,2696.54,Case rate,100% of GA Medicaid ,3370.67,9351.03,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13701.55,102,MS-DRG,10961.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,13432.89,100,MS-DRG,10746.31,Case rate,100% of Medicare MS-DRG,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,7664.89,13701.55,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5452.13,100,CUSTOM-DRG,4361.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8750.16,102,MS-DRG,7000.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5452.13,100,CUSTOM-DRG,4361.7,Case rate,100% of GA Medicaid ,8578.59,100,MS-DRG,6862.87,Case rate,100% of Medicare MS-DRG,5452.13,100,CUSTOM-DRG,4361.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5452.13,100,CUSTOM-DRG,4361.7,Case rate,100% of GA Medicaid ,5452.13,8750.16,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3857.1,100,CUSTOM-DRG,3085.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6715.73,102,MS-DRG,5372.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3857.1,100,CUSTOM-DRG,3085.68,Case rate,100% of GA Medicaid ,6584.05,100,MS-DRG,5267.24,Case rate,100% of Medicare MS-DRG,3857.1,100,CUSTOM-DRG,3085.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3857.1,100,CUSTOM-DRG,3085.68,Case rate,100% of GA Medicaid ,3857.1,6715.73,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10520.88,100,CUSTOM-DRG,8416.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16248.24,102,MS-DRG,12998.59,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10520.88,100,CUSTOM-DRG,8416.7,Case rate,100% of GA Medicaid ,15929.65,100,MS-DRG,12743.72,Case rate,100% of Medicare MS-DRG,10520.88,100,CUSTOM-DRG,8416.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10520.88,100,CUSTOM-DRG,8416.7,Case rate,100% of GA Medicaid ,10520.88,16248.24,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6385.66,100,CUSTOM-DRG,5108.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12079.13,102,MS-DRG,9663.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6385.66,100,CUSTOM-DRG,5108.53,Case rate,100% of GA Medicaid ,11842.28,100,MS-DRG,9473.82,Case rate,100% of Medicare MS-DRG,6385.66,100,CUSTOM-DRG,5108.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6385.66,100,CUSTOM-DRG,5108.53,Case rate,100% of GA Medicaid ,6385.66,12079.13,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8359.64,100,CUSTOM-DRG,6687.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17978.33,102,MS-DRG,14382.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8359.64,100,CUSTOM-DRG,6687.71,Case rate,100% of GA Medicaid ,17625.81,100,MS-DRG,14100.65,Case rate,100% of Medicare MS-DRG,8359.64,100,CUSTOM-DRG,6687.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8359.64,100,CUSTOM-DRG,6687.71,Case rate,100% of GA Medicaid ,8359.64,17978.33,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5332.46,100,CUSTOM-DRG,4265.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10744.11,102,MS-DRG,8595.29,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5332.46,100,CUSTOM-DRG,4265.97,Case rate,100% of GA Medicaid ,10533.44,100,MS-DRG,8426.75,Case rate,100% of Medicare MS-DRG,5332.46,100,CUSTOM-DRG,4265.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5332.46,100,CUSTOM-DRG,4265.97,Case rate,100% of GA Medicaid ,5332.46,10744.11,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10319.21,100,CUSTOM-DRG,8255.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17581.62,102,MS-DRG,14065.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10319.21,100,CUSTOM-DRG,8255.37,Case rate,100% of GA Medicaid ,17236.88,100,MS-DRG,13789.5,Case rate,100% of Medicare MS-DRG,10319.21,100,CUSTOM-DRG,8255.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10319.21,100,CUSTOM-DRG,8255.37,Case rate,100% of GA Medicaid ,10319.21,17581.62,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6001.17,100,CUSTOM-DRG,4800.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9842.2,102,MS-DRG,7873.76,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6001.17,100,CUSTOM-DRG,4800.94,Case rate,100% of GA Medicaid ,9649.22,100,MS-DRG,7719.38,Case rate,100% of Medicare MS-DRG,6001.17,100,CUSTOM-DRG,4800.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6001.17,100,CUSTOM-DRG,4800.94,Case rate,100% of GA Medicaid ,6001.17,9842.2,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7471.54,100,CUSTOM-DRG,5977.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12014.54,102,MS-DRG,9611.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7471.54,100,CUSTOM-DRG,5977.23,Case rate,100% of GA Medicaid ,11778.96,100,MS-DRG,9423.17,Case rate,100% of Medicare MS-DRG,7471.54,100,CUSTOM-DRG,5977.23,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7471.54,100,CUSTOM-DRG,5977.23,Case rate,100% of GA Medicaid ,7471.54,12014.54,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4371.79,100,CUSTOM-DRG,3497.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8344.57,102,MS-DRG,6675.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4371.79,100,CUSTOM-DRG,3497.43,Case rate,100% of GA Medicaid ,8180.95,100,MS-DRG,6544.76,Case rate,100% of Medicare MS-DRG,4371.79,100,CUSTOM-DRG,3497.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4371.79,100,CUSTOM-DRG,3497.43,Case rate,100% of GA Medicaid ,4371.79,8344.57,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13566.34,100,CUSTOM-DRG,10853.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18282.28,102,MS-DRG,14625.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13566.34,100,CUSTOM-DRG,10853.07,Case rate,100% of GA Medicaid ,17923.8,100,MS-DRG,14339.04,Case rate,100% of Medicare MS-DRG,13566.34,100,CUSTOM-DRG,10853.07,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13566.34,100,CUSTOM-DRG,10853.07,Case rate,100% of GA Medicaid ,13566.34,18282.28,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12277.68,100,CUSTOM-DRG,9822.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11778.5,102,MS-DRG,9422.8,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12277.68,100,CUSTOM-DRG,9822.14,Case rate,100% of GA Medicaid ,11547.55,100,MS-DRG,9238.04,Case rate,100% of Medicare MS-DRG,12277.68,100,CUSTOM-DRG,9822.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12277.68,100,CUSTOM-DRG,9822.14,Case rate,100% of GA Medicaid ,11547.55,12277.68,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8391.22,100,CUSTOM-DRG,6712.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15020.86,102,MS-DRG,12016.69,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8391.22,100,CUSTOM-DRG,6712.98,Case rate,100% of GA Medicaid ,14726.33,100,MS-DRG,11781.06,Case rate,100% of Medicare MS-DRG,8391.22,100,CUSTOM-DRG,6712.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8391.22,100,CUSTOM-DRG,6712.98,Case rate,100% of GA Medicaid ,8391.22,15020.86,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9759.22,102,MS-DRG,7807.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,9567.86,100,MS-DRG,7654.29,Case rate,100% of Medicare MS-DRG,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7772.37,100,CUSTOM-DRG,6217.9,Case rate,100% of GA Medicaid ,7772.37,9759.22,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10829.47,100,CUSTOM-DRG,8663.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15526.89,102,MS-DRG,12421.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10829.47,100,CUSTOM-DRG,8663.58,Case rate,100% of GA Medicaid ,15222.44,100,MS-DRG,12177.95,Case rate,100% of Medicare MS-DRG,10829.47,100,CUSTOM-DRG,8663.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10829.47,100,CUSTOM-DRG,8663.58,Case rate,100% of GA Medicaid ,10829.47,15526.89,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9358.85,102,MS-DRG,7487.08,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,9175.34,100,MS-DRG,7340.27,Case rate,100% of Medicare MS-DRG,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,4525.25,9358.85,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7374.55,102,MS-DRG,5899.64,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,7229.95,100,MS-DRG,5783.96,Case rate,100% of Medicare MS-DRG,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4525.25,100,CUSTOM-DRG,3620.2,Case rate,100% of GA Medicaid ,4525.25,7374.55,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4403.37,100,CUSTOM-DRG,3522.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10277,102,MS-DRG,8221.6,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4403.37,100,CUSTOM-DRG,3522.7,Case rate,100% of GA Medicaid ,10075.49,100,MS-DRG,8060.39,Case rate,100% of Medicare MS-DRG,4403.37,100,CUSTOM-DRG,3522.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4403.37,100,CUSTOM-DRG,3522.7,Case rate,100% of GA Medicaid ,4403.37,10277,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3160.14,100,CUSTOM-DRG,2528.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6862.86,102,MS-DRG,5490.29,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3160.14,100,CUSTOM-DRG,2528.11,Case rate,100% of GA Medicaid ,6728.29,100,MS-DRG,5382.63,Case rate,100% of Medicare MS-DRG,3160.14,100,CUSTOM-DRG,2528.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3160.14,100,CUSTOM-DRG,2528.11,Case rate,100% of GA Medicaid ,3160.14,6862.86,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5129.69,100,CUSTOM-DRG,4103.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13424.94,102,MS-DRG,10739.95,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5129.69,100,CUSTOM-DRG,4103.75,Case rate,100% of GA Medicaid ,13161.71,100,MS-DRG,10529.37,Case rate,100% of Medicare MS-DRG,5129.69,100,CUSTOM-DRG,4103.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5129.69,100,CUSTOM-DRG,4103.75,Case rate,100% of GA Medicaid ,5129.69,13424.94,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4610.57,100,CUSTOM-DRG,3688.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7313.36,102,MS-DRG,5850.69,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4610.57,100,CUSTOM-DRG,3688.46,Case rate,100% of GA Medicaid ,7169.96,100,MS-DRG,5735.97,Case rate,100% of Medicare MS-DRG,4610.57,100,CUSTOM-DRG,3688.46,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4610.57,100,CUSTOM-DRG,3688.46,Case rate,100% of GA Medicaid ,4610.57,7313.36,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4790.63,100,CUSTOM-DRG,3832.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8640.12,102,MS-DRG,6912.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4790.63,100,CUSTOM-DRG,3832.5,Case rate,100% of GA Medicaid ,8470.71,100,MS-DRG,6776.57,Case rate,100% of Medicare MS-DRG,4790.63,100,CUSTOM-DRG,3832.5,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4790.63,100,CUSTOM-DRG,3832.5,Case rate,100% of GA Medicaid ,4790.63,8640.12,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3000.03,100,CUSTOM-DRG,2400.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6151.3,102,MS-DRG,4921.04,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3000.03,100,CUSTOM-DRG,2400.02,Case rate,100% of GA Medicaid ,6030.69,100,MS-DRG,4824.55,Case rate,100% of Medicare MS-DRG,3000.03,100,CUSTOM-DRG,2400.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3000.03,100,CUSTOM-DRG,2400.02,Case rate,100% of GA Medicaid ,3000.03,6151.3,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10553.01,100,CUSTOM-DRG,8442.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18001.52,102,MS-DRG,14401.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10553.01,100,CUSTOM-DRG,8442.41,Case rate,100% of GA Medicaid ,17648.55,100,MS-DRG,14118.84,Case rate,100% of Medicare MS-DRG,10553.01,100,CUSTOM-DRG,8442.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10553.01,100,CUSTOM-DRG,8442.41,Case rate,100% of GA Medicaid ,10553.01,18001.52,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6985.11,100,CUSTOM-DRG,5588.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10436.83,102,MS-DRG,8349.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6985.11,100,CUSTOM-DRG,5588.09,Case rate,100% of GA Medicaid ,10232.19,100,MS-DRG,8185.75,Case rate,100% of Medicare MS-DRG,6985.11,100,CUSTOM-DRG,5588.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6985.11,100,CUSTOM-DRG,5588.09,Case rate,100% of GA Medicaid ,6985.11,10436.83,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15785.19,100,CUSTOM-DRG,12628.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32193.35,102,MS-DRG,25754.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15785.19,100,CUSTOM-DRG,12628.15,Case rate,100% of GA Medicaid ,31562.11,100,MS-DRG,25249.69,Case rate,100% of Medicare MS-DRG,15785.19,100,CUSTOM-DRG,12628.15,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15785.19,100,CUSTOM-DRG,12628.15,Case rate,100% of GA Medicaid ,15785.19,32193.35,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8844.41,100,CUSTOM-DRG,7075.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16346.8,102,MS-DRG,13077.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8844.41,100,CUSTOM-DRG,7075.53,Case rate,100% of GA Medicaid ,16026.27,100,MS-DRG,12821.02,Case rate,100% of Medicare MS-DRG,8844.41,100,CUSTOM-DRG,7075.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8844.41,100,CUSTOM-DRG,7075.53,Case rate,100% of GA Medicaid ,8844.41,16346.8,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6657.68,100,CUSTOM-DRG,5326.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11301.47,102,MS-DRG,9041.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6657.68,100,CUSTOM-DRG,5326.14,Case rate,100% of GA Medicaid ,11079.87,100,MS-DRG,8863.9,Case rate,100% of Medicare MS-DRG,6657.68,100,CUSTOM-DRG,5326.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6657.68,100,CUSTOM-DRG,5326.14,Case rate,100% of GA Medicaid ,6657.68,11301.47,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14200.14,100,CUSTOM-DRG,11360.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,29949.79,102,MS-DRG,23959.83,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14200.14,100,CUSTOM-DRG,11360.11,Case rate,100% of GA Medicaid ,29362.54,100,MS-DRG,23490.03,Case rate,100% of Medicare MS-DRG,14200.14,100,CUSTOM-DRG,11360.11,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14200.14,100,CUSTOM-DRG,11360.11,Case rate,100% of GA Medicaid ,14200.14,29949.79,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9946.36,100,CUSTOM-DRG,7957.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14799.72,102,MS-DRG,11839.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9946.36,100,CUSTOM-DRG,7957.09,Case rate,100% of GA Medicaid ,14509.53,100,MS-DRG,11607.62,Case rate,100% of Medicare MS-DRG,9946.36,100,CUSTOM-DRG,7957.09,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9946.36,100,CUSTOM-DRG,7957.09,Case rate,100% of GA Medicaid ,9946.36,14799.72,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10760.66,102,MS-DRG,8608.53,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,10549.67,100,MS-DRG,8439.74,Case rate,100% of Medicare MS-DRG,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,5397.28,10760.66,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6506.99,100,CUSTOM-DRG,5205.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14757.49,102,MS-DRG,11805.99,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6506.99,100,CUSTOM-DRG,5205.59,Case rate,100% of GA Medicaid ,14468.13,100,MS-DRG,11574.5,Case rate,100% of Medicare MS-DRG,6506.99,100,CUSTOM-DRG,5205.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6506.99,100,CUSTOM-DRG,5205.59,Case rate,100% of GA Medicaid ,6506.99,14757.49,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4913.62,100,CUSTOM-DRG,3930.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9669.39,102,MS-DRG,7735.51,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4913.62,100,CUSTOM-DRG,3930.9,Case rate,100% of GA Medicaid ,9479.79,100,MS-DRG,7583.83,Case rate,100% of Medicare MS-DRG,4913.62,100,CUSTOM-DRG,3930.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4913.62,100,CUSTOM-DRG,3930.9,Case rate,100% of GA Medicaid ,4913.62,9669.39,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6608.37,100,CUSTOM-DRG,5286.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15589.82,102,MS-DRG,12471.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6608.37,100,CUSTOM-DRG,5286.7,Case rate,100% of GA Medicaid ,15284.14,100,MS-DRG,12227.31,Case rate,100% of Medicare MS-DRG,6608.37,100,CUSTOM-DRG,5286.7,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6608.37,100,CUSTOM-DRG,5286.7,Case rate,100% of GA Medicaid ,6608.37,15589.82,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4239.93,100,CUSTOM-DRG,3391.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8848.46,102,MS-DRG,7078.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4239.93,100,CUSTOM-DRG,3391.94,Case rate,100% of GA Medicaid ,8674.96,100,MS-DRG,6939.97,Case rate,100% of Medicare MS-DRG,4239.93,100,CUSTOM-DRG,3391.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4239.93,100,CUSTOM-DRG,3391.94,Case rate,100% of GA Medicaid ,4239.93,8848.46,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6325.82,100,CUSTOM-DRG,5060.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13881.26,102,MS-DRG,11105.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6325.82,100,CUSTOM-DRG,5060.66,Case rate,100% of GA Medicaid ,13609.08,100,MS-DRG,10887.26,Case rate,100% of Medicare MS-DRG,6325.82,100,CUSTOM-DRG,5060.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6325.82,100,CUSTOM-DRG,5060.66,Case rate,100% of GA Medicaid ,6325.82,13881.26,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4685.92,100,CUSTOM-DRG,3748.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7880.4,102,MS-DRG,6304.32,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4685.92,100,CUSTOM-DRG,3748.74,Case rate,100% of GA Medicaid ,7725.88,100,MS-DRG,6180.7,Case rate,100% of Medicare MS-DRG,4685.92,100,CUSTOM-DRG,3748.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4685.92,100,CUSTOM-DRG,3748.74,Case rate,100% of GA Medicaid ,4685.92,7880.4,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5080.94,100,CUSTOM-DRG,4064.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11635.23,102,MS-DRG,9308.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5080.94,100,CUSTOM-DRG,4064.75,Case rate,100% of GA Medicaid ,11407.09,100,MS-DRG,9125.67,Case rate,100% of Medicare MS-DRG,5080.94,100,CUSTOM-DRG,4064.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5080.94,100,CUSTOM-DRG,4064.75,Case rate,100% of GA Medicaid ,5080.94,11635.23,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11009.53,100,CUSTOM-DRG,8807.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20847.17,102,MS-DRG,16677.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11009.53,100,CUSTOM-DRG,8807.62,Case rate,100% of GA Medicaid ,20438.4,100,MS-DRG,16350.72,Case rate,100% of Medicare MS-DRG,11009.53,100,CUSTOM-DRG,8807.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11009.53,100,CUSTOM-DRG,8807.62,Case rate,100% of GA Medicaid ,11009.53,20847.17,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5959.06,100,CUSTOM-DRG,4767.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11263.37,102,MS-DRG,9010.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5959.06,100,CUSTOM-DRG,4767.25,Case rate,100% of GA Medicaid ,11042.52,100,MS-DRG,8834.02,Case rate,100% of Medicare MS-DRG,5959.06,100,CUSTOM-DRG,4767.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5959.06,100,CUSTOM-DRG,4767.25,Case rate,100% of GA Medicaid ,5959.06,11263.37,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7116.41,100,CUSTOM-DRG,5693.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15342.2,102,MS-DRG,12273.76,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7116.41,100,CUSTOM-DRG,5693.13,Case rate,100% of GA Medicaid ,15041.37,100,MS-DRG,12033.1,Case rate,100% of Medicare MS-DRG,7116.41,100,CUSTOM-DRG,5693.13,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7116.41,100,CUSTOM-DRG,5693.13,Case rate,100% of GA Medicaid ,7116.41,15342.2,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6424.99,100,CUSTOM-DRG,5139.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9166.14,102,MS-DRG,7332.91,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6424.99,100,CUSTOM-DRG,5139.99,Case rate,100% of GA Medicaid ,8986.41,100,MS-DRG,7189.13,Case rate,100% of Medicare MS-DRG,6424.99,100,CUSTOM-DRG,5139.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6424.99,100,CUSTOM-DRG,5139.99,Case rate,100% of GA Medicaid ,6424.99,9166.14,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3961.26,100,CUSTOM-DRG,3169.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8547.68,102,MS-DRG,6838.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3961.26,100,CUSTOM-DRG,3169.01,Case rate,100% of GA Medicaid ,8380.08,100,MS-DRG,6704.06,Case rate,100% of Medicare MS-DRG,3961.26,100,CUSTOM-DRG,3169.01,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3961.26,100,CUSTOM-DRG,3169.01,Case rate,100% of GA Medicaid ,3961.26,8547.68,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5528.59,100,CUSTOM-DRG,4422.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12353.27,102,MS-DRG,9882.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5528.59,100,CUSTOM-DRG,4422.87,Case rate,100% of GA Medicaid ,12111.05,100,MS-DRG,9688.84,Case rate,100% of Medicare MS-DRG,5528.59,100,CUSTOM-DRG,4422.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5528.59,100,CUSTOM-DRG,4422.87,Case rate,100% of GA Medicaid ,5528.59,12353.27,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4467.63,100,CUSTOM-DRG,3574.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8566.56,102,MS-DRG,6853.25,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4467.63,100,CUSTOM-DRG,3574.1,Case rate,100% of GA Medicaid ,8398.59,100,MS-DRG,6718.87,Case rate,100% of Medicare MS-DRG,4467.63,100,CUSTOM-DRG,3574.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4467.63,100,CUSTOM-DRG,3574.1,Case rate,100% of GA Medicaid ,4467.63,8566.56,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3399.48,100,CUSTOM-DRG,2719.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6311.44,102,MS-DRG,5049.15,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3399.48,100,CUSTOM-DRG,2719.58,Case rate,100% of GA Medicaid ,6187.69,100,MS-DRG,4950.15,Case rate,100% of Medicare MS-DRG,3399.48,100,CUSTOM-DRG,2719.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3399.48,100,CUSTOM-DRG,2719.58,Case rate,100% of GA Medicaid ,3399.48,6311.44,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4078.71,100,CUSTOM-DRG,3262.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8584.79,102,MS-DRG,6867.83,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4078.71,100,CUSTOM-DRG,3262.97,Case rate,100% of GA Medicaid ,8416.46,100,MS-DRG,6733.17,Case rate,100% of Medicare MS-DRG,4078.71,100,CUSTOM-DRG,3262.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4078.71,100,CUSTOM-DRG,3262.97,Case rate,100% of GA Medicaid ,4078.71,8584.79,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3176.76,100,CUSTOM-DRG,2541.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6047.13,102,MS-DRG,4837.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3176.76,100,CUSTOM-DRG,2541.41,Case rate,100% of GA Medicaid ,5928.56,100,MS-DRG,4742.85,Case rate,100% of Medicare MS-DRG,3176.76,100,CUSTOM-DRG,2541.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3176.76,100,CUSTOM-DRG,2541.41,Case rate,100% of GA Medicaid ,3176.76,6047.13,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4529.13,100,CUSTOM-DRG,3623.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10088.17,102,MS-DRG,8070.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4529.13,100,CUSTOM-DRG,3623.3,Case rate,100% of GA Medicaid ,9890.36,100,MS-DRG,7912.29,Case rate,100% of Medicare MS-DRG,4529.13,100,CUSTOM-DRG,3623.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4529.13,100,CUSTOM-DRG,3623.3,Case rate,100% of GA Medicaid ,4529.13,10088.17,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7202.84,100,CUSTOM-DRG,5762.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12786.41,102,MS-DRG,10229.13,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7202.84,100,CUSTOM-DRG,5762.27,Case rate,100% of GA Medicaid ,12535.7,100,MS-DRG,10028.56,Case rate,100% of Medicare MS-DRG,7202.84,100,CUSTOM-DRG,5762.27,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7202.84,100,CUSTOM-DRG,5762.27,Case rate,100% of GA Medicaid ,7202.84,12786.41,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3589.51,100,CUSTOM-DRG,2871.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7304.25,102,MS-DRG,5843.4,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3589.51,100,CUSTOM-DRG,2871.61,Case rate,100% of GA Medicaid ,7161.03,100,MS-DRG,5728.82,Case rate,100% of Medicare MS-DRG,3589.51,100,CUSTOM-DRG,2871.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3589.51,100,CUSTOM-DRG,2871.61,Case rate,100% of GA Medicaid ,3589.51,7304.25,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3593.39,100,CUSTOM-DRG,2874.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6770.4,102,MS-DRG,5416.32,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3593.39,100,CUSTOM-DRG,2874.71,Case rate,100% of GA Medicaid ,6637.65,100,MS-DRG,5310.12,Case rate,100% of Medicare MS-DRG,3593.39,100,CUSTOM-DRG,2874.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3593.39,100,CUSTOM-DRG,2874.71,Case rate,100% of GA Medicaid ,3593.39,6770.4,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2975.1,100,CUSTOM-DRG,2380.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8544.43,102,MS-DRG,6835.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2975.1,100,CUSTOM-DRG,2380.08,Case rate,100% of GA Medicaid ,8376.89,100,MS-DRG,6701.51,Case rate,100% of Medicare MS-DRG,2975.1,100,CUSTOM-DRG,2380.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2975.1,100,CUSTOM-DRG,2380.08,Case rate,100% of GA Medicaid ,2975.1,8544.43,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,14673.84,102,MS-DRG,11739.07,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,14386.12,100,MS-DRG,11508.9,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,14386.12,14673.84,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,8771.64,102,MS-DRG,7017.31,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,8599.65,100,MS-DRG,6879.72,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,8599.65,8771.64,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,7744.33,102,MS-DRG,6195.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7592.48,100,MS-DRG,6073.98,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7592.48,7744.33,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,14489.16,102,MS-DRG,11591.33,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,14205.06,100,MS-DRG,11364.05,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,14205.06,14489.16,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3954.06,100,CUSTOM-DRG,3163.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8947.41,102,MS-DRG,7157.93,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3954.06,100,CUSTOM-DRG,3163.25,Case rate,100% of GA Medicaid ,8771.97,100,MS-DRG,7017.58,Case rate,100% of Medicare MS-DRG,3954.06,100,CUSTOM-DRG,3163.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3954.06,100,CUSTOM-DRG,3163.25,Case rate,100% of GA Medicaid ,3954.06,8947.41,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4295.89,100,CUSTOM-DRG,3436.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7670.77,102,MS-DRG,6136.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4295.89,100,CUSTOM-DRG,3436.71,Case rate,100% of GA Medicaid ,7520.36,100,MS-DRG,6016.29,Case rate,100% of Medicare MS-DRG,4295.89,100,CUSTOM-DRG,3436.71,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4295.89,100,CUSTOM-DRG,3436.71,Case rate,100% of GA Medicaid ,4295.89,7670.77,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11081.55,100,CUSTOM-DRG,8865.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15068.07,102,MS-DRG,12054.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11081.55,100,CUSTOM-DRG,8865.24,Case rate,100% of GA Medicaid ,14772.62,100,MS-DRG,11818.1,Case rate,100% of Medicare MS-DRG,11081.55,100,CUSTOM-DRG,8865.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11081.55,100,CUSTOM-DRG,8865.24,Case rate,100% of GA Medicaid ,11081.55,15068.07,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3952.95,100,CUSTOM-DRG,3162.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,49692.17,102,MS-DRG,39753.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3952.95,100,CUSTOM-DRG,3162.36,Case rate,100% of GA Medicaid ,48717.81,100,MS-DRG,38974.25,Case rate,100% of Medicare MS-DRG,3952.95,100,CUSTOM-DRG,3162.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3952.95,100,CUSTOM-DRG,3162.36,Case rate,100% of GA Medicaid ,3952.95,49692.17,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2079.8,100,CUSTOM-DRG,1663.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,33936.71,102,MS-DRG,27149.37,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2079.8,100,CUSTOM-DRG,1663.84,Case rate,100% of GA Medicaid ,33271.28,100,MS-DRG,26617.02,Case rate,100% of Medicare MS-DRG,2079.8,100,CUSTOM-DRG,1663.84,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2079.8,100,CUSTOM-DRG,1663.84,Case rate,100% of GA Medicaid ,2079.8,33936.71,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,1568.44,100,CUSTOM-DRG,1254.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20476.97,102,MS-DRG,16381.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,1568.44,100,CUSTOM-DRG,1254.75,Case rate,100% of GA Medicaid ,20075.46,100,MS-DRG,16060.37,Case rate,100% of Medicare MS-DRG,1568.44,100,CUSTOM-DRG,1254.75,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,1568.44,100,CUSTOM-DRG,1254.75,Case rate,100% of GA Medicaid ,1568.44,20476.97,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9685.41,100,CUSTOM-DRG,7748.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,34860.95,102,MS-DRG,27888.76,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9685.41,100,CUSTOM-DRG,7748.33,Case rate,100% of GA Medicaid ,34177.4,100,MS-DRG,27341.92,Case rate,100% of Medicare MS-DRG,9685.41,100,CUSTOM-DRG,7748.33,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9685.41,100,CUSTOM-DRG,7748.33,Case rate,100% of GA Medicaid ,9685.41,34860.95,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23684.99,100,CUSTOM-DRG,18947.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12339.2,102,MS-DRG,9871.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,23684.99,100,CUSTOM-DRG,18947.99,Case rate,100% of GA Medicaid ,12097.25,100,MS-DRG,9677.8,Case rate,100% of Medicare MS-DRG,23684.99,100,CUSTOM-DRG,18947.99,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23684.99,100,CUSTOM-DRG,18947.99,Case rate,100% of GA Medicaid ,12097.25,23684.99,
NORMAL NEWBORN,795,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,1209.43,100,CUSTOM-DRG,967.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3417.69,102,MS-DRG,2734.15,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,1209.43,100,CUSTOM-DRG,967.54,Case rate,100% of GA Medicaid ,3350.68,100,MS-DRG,2680.54,Case rate,100% of Medicare MS-DRG,1209.43,100,CUSTOM-DRG,967.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,1209.43,100,CUSTOM-DRG,967.54,Case rate,100% of GA Medicaid ,1209.43,3417.69,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11747.02,102,MS-DRG,9397.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,11516.69,100,MS-DRG,9213.35,Case rate,100% of Medicare MS-DRG,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,5833.85,11747.02,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8588.04,102,MS-DRG,6870.43,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,8419.65,100,MS-DRG,6735.72,Case rate,100% of Medicare MS-DRG,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5833.85,100,CUSTOM-DRG,4667.08,Case rate,100% of GA Medicaid ,5833.85,8588.04,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,7541.21,102,MS-DRG,6032.97,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7393.34,100,MS-DRG,5914.67,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7393.34,7541.21,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15878.82,100,CUSTOM-DRG,12703.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,41033.45,102,MS-DRG,32826.76,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15878.82,100,CUSTOM-DRG,12703.06,Case rate,100% of GA Medicaid ,40228.87,100,MS-DRG,32183.1,Case rate,100% of Medicare MS-DRG,15878.82,100,CUSTOM-DRG,12703.06,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15878.82,100,CUSTOM-DRG,12703.06,Case rate,100% of GA Medicaid ,15878.82,41033.45,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11846.1,100,CUSTOM-DRG,9476.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23335.88,102,MS-DRG,18668.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11846.1,100,CUSTOM-DRG,9476.88,Case rate,100% of GA Medicaid ,22878.31,100,MS-DRG,18302.65,Case rate,100% of Medicare MS-DRG,11846.1,100,CUSTOM-DRG,9476.88,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11846.1,100,CUSTOM-DRG,9476.88,Case rate,100% of GA Medicaid ,11846.1,23335.88,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7785.12,100,CUSTOM-DRG,6228.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14822.1,102,MS-DRG,11857.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7785.12,100,CUSTOM-DRG,6228.1,Case rate,100% of GA Medicaid ,14531.47,100,MS-DRG,11625.18,Case rate,100% of Medicare MS-DRG,7785.12,100,CUSTOM-DRG,6228.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7785.12,100,CUSTOM-DRG,6228.1,Case rate,100% of GA Medicaid ,7785.12,14822.1,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15320.92,100,CUSTOM-DRG,12256.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28413.5,102,MS-DRG,22730.8,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15320.92,100,CUSTOM-DRG,12256.74,Case rate,100% of GA Medicaid ,27856.37,100,MS-DRG,22285.1,Case rate,100% of Medicare MS-DRG,15320.92,100,CUSTOM-DRG,12256.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15320.92,100,CUSTOM-DRG,12256.74,Case rate,100% of GA Medicaid ,15320.92,28413.5,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7389.55,100,CUSTOM-DRG,5911.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15389.4,102,MS-DRG,12311.52,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7389.55,100,CUSTOM-DRG,5911.64,Case rate,100% of GA Medicaid ,15087.65,100,MS-DRG,12070.12,Case rate,100% of Medicare MS-DRG,7389.55,100,CUSTOM-DRG,5911.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7389.55,100,CUSTOM-DRG,5911.64,Case rate,100% of GA Medicaid ,7389.55,15389.4,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6081.5,100,CUSTOM-DRG,4865.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10024.4,102,MS-DRG,8019.52,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6081.5,100,CUSTOM-DRG,4865.2,Case rate,100% of GA Medicaid ,9827.84,100,MS-DRG,7862.27,Case rate,100% of Medicare MS-DRG,6081.5,100,CUSTOM-DRG,4865.2,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6081.5,100,CUSTOM-DRG,4865.2,Case rate,100% of GA Medicaid ,6081.5,10024.4,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,8668.12,102,MS-DRG,6934.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,8498.16,100,MS-DRG,6798.53,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,8498.16,8668.12,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,6965.72,102,MS-DRG,5572.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,6829.14,100,MS-DRG,5463.31,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,6829.14,6965.72,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,6364.18,102,MS-DRG,5091.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,6239.39,100,MS-DRG,4991.51,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,6239.39,6364.18,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15895.45,100,CUSTOM-DRG,12716.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18138.16,102,MS-DRG,14510.53,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15895.45,100,CUSTOM-DRG,12716.36,Case rate,100% of GA Medicaid ,17782.51,100,MS-DRG,14226.01,Case rate,100% of Medicare MS-DRG,15895.45,100,CUSTOM-DRG,12716.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15895.45,100,CUSTOM-DRG,12716.36,Case rate,100% of GA Medicaid ,15895.45,18138.16,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7520.85,100,CUSTOM-DRG,6016.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9974.71,102,MS-DRG,7979.77,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7520.85,100,CUSTOM-DRG,6016.68,Case rate,100% of GA Medicaid ,9779.13,100,MS-DRG,7823.3,Case rate,100% of Medicare MS-DRG,7520.85,100,CUSTOM-DRG,6016.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7520.85,100,CUSTOM-DRG,6016.68,Case rate,100% of GA Medicaid ,7520.85,9974.71,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3829.4,100,CUSTOM-DRG,3063.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8644.04,102,MS-DRG,6915.23,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3829.4,100,CUSTOM-DRG,3063.52,Case rate,100% of GA Medicaid ,8474.55,100,MS-DRG,6779.64,Case rate,100% of Medicare MS-DRG,3829.4,100,CUSTOM-DRG,3063.52,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3829.4,100,CUSTOM-DRG,3063.52,Case rate,100% of GA Medicaid ,3829.4,8644.04,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8302.02,100,CUSTOM-DRG,6641.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11624.47,102,MS-DRG,9299.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8302.02,100,CUSTOM-DRG,6641.62,Case rate,100% of GA Medicaid ,11396.54,100,MS-DRG,9117.23,Case rate,100% of Medicare MS-DRG,8302.02,100,CUSTOM-DRG,6641.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8302.02,100,CUSTOM-DRG,6641.62,Case rate,100% of GA Medicaid ,8302.02,11624.47,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4703.09,100,CUSTOM-DRG,3762.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7968.28,102,MS-DRG,6374.62,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4703.09,100,CUSTOM-DRG,3762.47,Case rate,100% of GA Medicaid ,7812.04,100,MS-DRG,6249.63,Case rate,100% of Medicare MS-DRG,4703.09,100,CUSTOM-DRG,3762.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4703.09,100,CUSTOM-DRG,3762.47,Case rate,100% of GA Medicaid ,4703.09,7968.28,
COAGULATION DISORDERS,813,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6763.5,100,CUSTOM-DRG,5410.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12919.74,102,MS-DRG,10335.79,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6763.5,100,CUSTOM-DRG,5410.8,Case rate,100% of GA Medicaid ,12666.41,100,MS-DRG,10133.13,Case rate,100% of Medicare MS-DRG,6763.5,100,CUSTOM-DRG,5410.8,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6763.5,100,CUSTOM-DRG,5410.8,Case rate,100% of GA Medicaid ,6763.5,12919.74,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6230.53,100,CUSTOM-DRG,4984.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17624.68,102,MS-DRG,14099.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6230.53,100,CUSTOM-DRG,4984.42,Case rate,100% of GA Medicaid ,17279.1,100,MS-DRG,13823.28,Case rate,100% of Medicare MS-DRG,6230.53,100,CUSTOM-DRG,4984.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6230.53,100,CUSTOM-DRG,4984.42,Case rate,100% of GA Medicaid ,6230.53,17624.68,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4886.47,100,CUSTOM-DRG,3909.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8576.98,102,MS-DRG,6861.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4886.47,100,CUSTOM-DRG,3909.18,Case rate,100% of GA Medicaid ,8408.8,100,MS-DRG,6727.04,Case rate,100% of Medicare MS-DRG,4886.47,100,CUSTOM-DRG,3909.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4886.47,100,CUSTOM-DRG,3909.18,Case rate,100% of GA Medicaid ,4886.47,8576.98,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3212.22,100,CUSTOM-DRG,2569.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6728.08,102,MS-DRG,5382.46,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3212.22,100,CUSTOM-DRG,2569.78,Case rate,100% of GA Medicaid ,6596.16,100,MS-DRG,5276.93,Case rate,100% of Medicare MS-DRG,3212.22,100,CUSTOM-DRG,2569.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3212.22,100,CUSTOM-DRG,2569.78,Case rate,100% of GA Medicaid ,3212.22,6728.08,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,23328.42,102,MS-DRG,18662.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,22871,100,MS-DRG,18296.8,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,22871,23328.42,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,11852.22,102,MS-DRG,9481.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,11619.82,100,MS-DRG,9295.86,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,11619.82,11852.22,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,8010.59,102,MS-DRG,6408.47,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7853.52,100,MS-DRG,6282.82,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7853.52,8010.59,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26121.03,100,CUSTOM-DRG,20896.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,50078.09,102,MS-DRG,40062.47,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,26121.03,100,CUSTOM-DRG,20896.82,Case rate,100% of GA Medicaid ,49096.17,100,MS-DRG,39276.94,Case rate,100% of Medicare MS-DRG,26121.03,100,CUSTOM-DRG,20896.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26121.03,100,CUSTOM-DRG,20896.82,Case rate,100% of GA Medicaid ,26121.03,50078.09,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18486,102,MS-DRG,14788.8,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,18123.53,100,MS-DRG,14498.82,Case rate,100% of Medicare MS-DRG,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11031.13,100,CUSTOM-DRG,8824.9,Case rate,100% of GA Medicaid ,11031.13,18486,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6247.15,100,CUSTOM-DRG,4997.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10259.6,102,MS-DRG,8207.68,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6247.15,100,CUSTOM-DRG,4997.72,Case rate,100% of GA Medicaid ,10058.43,100,MS-DRG,8046.74,Case rate,100% of Medicare MS-DRG,6247.15,100,CUSTOM-DRG,4997.72,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6247.15,100,CUSTOM-DRG,4997.72,Case rate,100% of GA Medicaid ,6247.15,10259.6,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20620.7,100,CUSTOM-DRG,16496.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,37284.23,102,MS-DRG,29827.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,20620.7,100,CUSTOM-DRG,16496.56,Case rate,100% of GA Medicaid ,36553.17,100,MS-DRG,29242.54,Case rate,100% of Medicare MS-DRG,20620.7,100,CUSTOM-DRG,16496.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20620.7,100,CUSTOM-DRG,16496.56,Case rate,100% of GA Medicaid ,20620.7,37284.23,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11121.99,100,CUSTOM-DRG,8897.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18492.63,102,MS-DRG,14794.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11121.99,100,CUSTOM-DRG,8897.59,Case rate,100% of GA Medicaid ,18130.03,100,MS-DRG,14504.02,Case rate,100% of Medicare MS-DRG,11121.99,100,CUSTOM-DRG,8897.59,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11121.99,100,CUSTOM-DRG,8897.59,Case rate,100% of GA Medicaid ,11121.99,18492.63,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7288.71,100,CUSTOM-DRG,5830.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10695.23,102,MS-DRG,8556.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7288.71,100,CUSTOM-DRG,5830.97,Case rate,100% of GA Medicaid ,10485.52,100,MS-DRG,8388.42,Case rate,100% of Medicare MS-DRG,7288.71,100,CUSTOM-DRG,5830.97,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7288.71,100,CUSTOM-DRG,5830.97,Case rate,100% of GA Medicaid ,7288.71,10695.23,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21838.99,100,CUSTOM-DRG,17471.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,38326.09,102,MS-DRG,30660.87,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,21838.99,100,CUSTOM-DRG,17471.19,Case rate,100% of GA Medicaid ,37574.6,100,MS-DRG,30059.68,Case rate,100% of Medicare MS-DRG,21838.99,100,CUSTOM-DRG,17471.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,21838.99,100,CUSTOM-DRG,17471.19,Case rate,100% of GA Medicaid ,21838.99,38326.09,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9723.09,100,CUSTOM-DRG,7778.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19190.79,102,MS-DRG,15352.63,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9723.09,100,CUSTOM-DRG,7778.47,Case rate,100% of GA Medicaid ,18814.5,100,MS-DRG,15051.6,Case rate,100% of Medicare MS-DRG,9723.09,100,CUSTOM-DRG,7778.47,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9723.09,100,CUSTOM-DRG,7778.47,Case rate,100% of GA Medicaid ,9723.09,19190.79,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7007.27,100,CUSTOM-DRG,5605.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13585.6,102,MS-DRG,10868.48,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7007.27,100,CUSTOM-DRG,5605.82,Case rate,100% of GA Medicaid ,13319.22,100,MS-DRG,10655.38,Case rate,100% of Medicare MS-DRG,7007.27,100,CUSTOM-DRG,5605.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7007.27,100,CUSTOM-DRG,5605.82,Case rate,100% of GA Medicaid ,7007.27,13585.6,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12765.77,100,CUSTOM-DRG,10212.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26119.42,102,MS-DRG,20895.54,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12765.77,100,CUSTOM-DRG,10212.62,Case rate,100% of GA Medicaid ,25607.27,100,MS-DRG,20485.82,Case rate,100% of Medicare MS-DRG,12765.77,100,CUSTOM-DRG,10212.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12765.77,100,CUSTOM-DRG,10212.62,Case rate,100% of GA Medicaid ,12765.77,26119.42,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5293.68,100,CUSTOM-DRG,4234.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13095.32,102,MS-DRG,10476.26,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5293.68,100,CUSTOM-DRG,4234.94,Case rate,100% of GA Medicaid ,12838.55,100,MS-DRG,10270.84,Case rate,100% of Medicare MS-DRG,5293.68,100,CUSTOM-DRG,4234.94,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5293.68,100,CUSTOM-DRG,4234.94,Case rate,100% of GA Medicaid ,5293.68,13095.32,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,9104.95,102,MS-DRG,7283.96,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,8926.42,100,MS-DRG,7141.14,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,8926.42,9104.95,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,6907.13,102,MS-DRG,5525.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,6771.7,100,MS-DRG,5417.36,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,6771.7,6907.13,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,5436.49,102,MS-DRG,4349.19,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,5329.89,100,MS-DRG,4263.91,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,5329.89,5436.49,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,45668.59,100,CUSTOM-DRG,36534.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,46370.3,102,MS-DRG,37096.24,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,45668.59,100,CUSTOM-DRG,36534.87,Case rate,100% of GA Medicaid ,45461.08,100,MS-DRG,36368.86,Case rate,100% of Medicare MS-DRG,45668.59,100,CUSTOM-DRG,36534.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,45668.59,100,CUSTOM-DRG,36534.87,Case rate,100% of GA Medicaid ,45461.08,46370.3,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13107.05,100,CUSTOM-DRG,10485.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18514.16,102,MS-DRG,14811.33,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,13107.05,100,CUSTOM-DRG,10485.64,Case rate,100% of GA Medicaid ,18151.14,100,MS-DRG,14520.91,Case rate,100% of Medicare MS-DRG,13107.05,100,CUSTOM-DRG,10485.64,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13107.05,100,CUSTOM-DRG,10485.64,Case rate,100% of GA Medicaid ,13107.05,18514.16,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5306.42,100,CUSTOM-DRG,4245.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11693.2,102,MS-DRG,9354.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5306.42,100,CUSTOM-DRG,4245.14,Case rate,100% of GA Medicaid ,11463.92,100,MS-DRG,9171.14,Case rate,100% of Medicare MS-DRG,5306.42,100,CUSTOM-DRG,4245.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5306.42,100,CUSTOM-DRG,4245.14,Case rate,100% of GA Medicaid ,5306.42,11693.2,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25913.27,100,CUSTOM-DRG,20730.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,40117.48,102,MS-DRG,32093.98,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,25913.27,100,CUSTOM-DRG,20730.62,Case rate,100% of GA Medicaid ,39330.86,100,MS-DRG,31464.69,Case rate,100% of Medicare MS-DRG,25913.27,100,CUSTOM-DRG,20730.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25913.27,100,CUSTOM-DRG,20730.62,Case rate,100% of GA Medicaid ,25913.27,40117.48,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8187.34,100,CUSTOM-DRG,6549.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16577.86,102,MS-DRG,13262.29,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8187.34,100,CUSTOM-DRG,6549.87,Case rate,100% of GA Medicaid ,16252.8,100,MS-DRG,13002.24,Case rate,100% of Medicare MS-DRG,8187.34,100,CUSTOM-DRG,6549.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8187.34,100,CUSTOM-DRG,6549.87,Case rate,100% of GA Medicaid ,8187.34,16577.86,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5564.6,100,CUSTOM-DRG,4451.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10792.13,102,MS-DRG,8633.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5564.6,100,CUSTOM-DRG,4451.68,Case rate,100% of GA Medicaid ,10580.52,100,MS-DRG,8464.42,Case rate,100% of Medicare MS-DRG,5564.6,100,CUSTOM-DRG,4451.68,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5564.6,100,CUSTOM-DRG,4451.68,Case rate,100% of GA Medicaid ,5564.6,10792.13,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23048.42,100,CUSTOM-DRG,18438.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25882.57,102,MS-DRG,20706.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,23048.42,100,CUSTOM-DRG,18438.74,Case rate,100% of GA Medicaid ,25375.07,100,MS-DRG,20300.06,Case rate,100% of Medicare MS-DRG,23048.42,100,CUSTOM-DRG,18438.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23048.42,100,CUSTOM-DRG,18438.74,Case rate,100% of GA Medicaid ,23048.42,25882.57,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7874.31,100,CUSTOM-DRG,6299.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13031.56,102,MS-DRG,10425.25,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7874.31,100,CUSTOM-DRG,6299.45,Case rate,100% of GA Medicaid ,12776.04,100,MS-DRG,10220.83,Case rate,100% of Medicare MS-DRG,7874.31,100,CUSTOM-DRG,6299.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7874.31,100,CUSTOM-DRG,6299.45,Case rate,100% of GA Medicaid ,7874.31,13031.56,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6303.66,100,CUSTOM-DRG,5042.93,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9047.01,102,MS-DRG,7237.61,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6303.66,100,CUSTOM-DRG,5042.93,Case rate,100% of GA Medicaid ,8869.62,100,MS-DRG,7095.7,Case rate,100% of Medicare MS-DRG,6303.66,100,CUSTOM-DRG,5042.93,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6303.66,100,CUSTOM-DRG,5042.93,Case rate,100% of GA Medicaid ,6303.66,9047.01,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7025.55,100,CUSTOM-DRG,5620.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15409.28,102,MS-DRG,12327.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7025.55,100,CUSTOM-DRG,5620.44,Case rate,100% of GA Medicaid ,15107.14,100,MS-DRG,12085.71,Case rate,100% of Medicare MS-DRG,7025.55,100,CUSTOM-DRG,5620.44,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7025.55,100,CUSTOM-DRG,5620.44,Case rate,100% of GA Medicaid ,7025.55,15409.28,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4750.18,100,CUSTOM-DRG,3800.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9638.12,102,MS-DRG,7710.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4750.18,100,CUSTOM-DRG,3800.14,Case rate,100% of GA Medicaid ,9449.14,100,MS-DRG,7559.31,Case rate,100% of Medicare MS-DRG,4750.18,100,CUSTOM-DRG,3800.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4750.18,100,CUSTOM-DRG,3800.14,Case rate,100% of GA Medicaid ,4750.18,9638.12,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4000.04,100,CUSTOM-DRG,3200.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7735.21,102,MS-DRG,6188.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4000.04,100,CUSTOM-DRG,3200.03,Case rate,100% of GA Medicaid ,7583.54,100,MS-DRG,6066.83,Case rate,100% of Medicare MS-DRG,4000.04,100,CUSTOM-DRG,3200.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4000.04,100,CUSTOM-DRG,3200.03,Case rate,100% of GA Medicaid ,4000.04,7735.21,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12156.35,100,CUSTOM-DRG,9725.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20240.94,102,MS-DRG,16192.75,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12156.35,100,CUSTOM-DRG,9725.08,Case rate,100% of GA Medicaid ,19844.06,100,MS-DRG,15875.25,Case rate,100% of Medicare MS-DRG,12156.35,100,CUSTOM-DRG,9725.08,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12156.35,100,CUSTOM-DRG,9725.08,Case rate,100% of GA Medicaid ,12156.35,20240.94,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6829.43,100,CUSTOM-DRG,5463.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10042.61,102,MS-DRG,8034.09,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6829.43,100,CUSTOM-DRG,5463.54,Case rate,100% of GA Medicaid ,9845.7,100,MS-DRG,7876.56,Case rate,100% of Medicare MS-DRG,6829.43,100,CUSTOM-DRG,5463.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6829.43,100,CUSTOM-DRG,5463.54,Case rate,100% of GA Medicaid ,6829.43,10042.61,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3413.88,100,CUSTOM-DRG,2731.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7548.38,102,MS-DRG,6038.7,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3413.88,100,CUSTOM-DRG,2731.1,Case rate,100% of GA Medicaid ,7400.37,100,MS-DRG,5920.3,Case rate,100% of Medicare MS-DRG,3413.88,100,CUSTOM-DRG,2731.1,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3413.88,100,CUSTOM-DRG,2731.1,Case rate,100% of GA Medicaid ,3413.88,7548.38,
RADIOTHERAPY,849,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4787.86,100,CUSTOM-DRG,3830.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22289.88,102,MS-DRG,17831.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4787.86,100,CUSTOM-DRG,3830.29,Case rate,100% of GA Medicaid ,21852.82,100,MS-DRG,17482.26,Case rate,100% of Medicare MS-DRG,4787.86,100,CUSTOM-DRG,3830.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4787.86,100,CUSTOM-DRG,3830.29,Case rate,100% of GA Medicaid ,4787.86,22289.88,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,31029.11,100,CUSTOM-DRG,24823.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,41403.66,102,MS-DRG,33122.93,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,31029.11,100,CUSTOM-DRG,24823.29,Case rate,100% of GA Medicaid ,40591.82,100,MS-DRG,32473.46,Case rate,100% of Medicare MS-DRG,31029.11,100,CUSTOM-DRG,24823.29,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,31029.11,100,CUSTOM-DRG,24823.29,Case rate,100% of GA Medicaid ,31029.11,41403.66,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12832.81,100,CUSTOM-DRG,10266.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16880.15,102,MS-DRG,13504.12,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12832.81,100,CUSTOM-DRG,10266.25,Case rate,100% of GA Medicaid ,16549.17,100,MS-DRG,13239.34,Case rate,100% of Medicare MS-DRG,12832.81,100,CUSTOM-DRG,10266.25,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12832.81,100,CUSTOM-DRG,10266.25,Case rate,100% of GA Medicaid ,12832.81,16880.15,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8095.92,100,CUSTOM-DRG,6476.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14094.13,102,MS-DRG,11275.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8095.92,100,CUSTOM-DRG,6476.74,Case rate,100% of GA Medicaid ,13817.77,100,MS-DRG,11054.22,Case rate,100% of Medicare MS-DRG,8095.92,100,CUSTOM-DRG,6476.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8095.92,100,CUSTOM-DRG,6476.74,Case rate,100% of GA Medicaid ,8095.92,14094.13,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22226.81,100,CUSTOM-DRG,17781.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,36675.52,102,MS-DRG,29340.42,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,22226.81,100,CUSTOM-DRG,17781.45,Case rate,100% of GA Medicaid ,35956.39,100,MS-DRG,28765.11,Case rate,100% of Medicare MS-DRG,22226.81,100,CUSTOM-DRG,17781.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22226.81,100,CUSTOM-DRG,17781.45,Case rate,100% of GA Medicaid ,22226.81,36675.52,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9890.4,100,CUSTOM-DRG,7912.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17687.64,102,MS-DRG,14150.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9890.4,100,CUSTOM-DRG,7912.32,Case rate,100% of GA Medicaid ,17340.82,100,MS-DRG,13872.66,Case rate,100% of Medicare MS-DRG,9890.4,100,CUSTOM-DRG,7912.32,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9890.4,100,CUSTOM-DRG,7912.32,Case rate,100% of GA Medicaid ,9890.4,17687.64,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8665.46,100,CUSTOM-DRG,6932.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10628.97,102,MS-DRG,8503.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8665.46,100,CUSTOM-DRG,6932.37,Case rate,100% of GA Medicaid ,10420.56,100,MS-DRG,8336.45,Case rate,100% of Medicare MS-DRG,8665.46,100,CUSTOM-DRG,6932.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8665.46,100,CUSTOM-DRG,6932.37,Case rate,100% of GA Medicaid ,8665.46,10628.97,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8701.47,100,CUSTOM-DRG,6961.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15255.23,102,MS-DRG,12204.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8701.47,100,CUSTOM-DRG,6961.18,Case rate,100% of GA Medicaid ,14956.11,100,MS-DRG,11964.89,Case rate,100% of Medicare MS-DRG,8701.47,100,CUSTOM-DRG,6961.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8701.47,100,CUSTOM-DRG,6961.18,Case rate,100% of GA Medicaid ,8701.47,15255.23,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4774.01,100,CUSTOM-DRG,3819.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8650.55,102,MS-DRG,6920.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4774.01,100,CUSTOM-DRG,3819.21,Case rate,100% of GA Medicaid ,8480.93,100,MS-DRG,6784.74,Case rate,100% of Medicare MS-DRG,4774.01,100,CUSTOM-DRG,3819.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4774.01,100,CUSTOM-DRG,3819.21,Case rate,100% of GA Medicaid ,4774.01,8650.55,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4474.84,100,CUSTOM-DRG,3579.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7851.76,102,MS-DRG,6281.41,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4474.84,100,CUSTOM-DRG,3579.87,Case rate,100% of GA Medicaid ,7697.8,100,MS-DRG,6158.24,Case rate,100% of Medicare MS-DRG,4474.84,100,CUSTOM-DRG,3579.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4474.84,100,CUSTOM-DRG,3579.87,Case rate,100% of GA Medicaid ,4474.84,7851.76,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4346.86,100,CUSTOM-DRG,3477.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13581.46,102,MS-DRG,10865.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4346.86,100,CUSTOM-DRG,3477.49,Case rate,100% of GA Medicaid ,13315.16,100,MS-DRG,10652.13,Case rate,100% of Medicare MS-DRG,4346.86,100,CUSTOM-DRG,3477.49,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4346.86,100,CUSTOM-DRG,3477.49,Case rate,100% of GA Medicaid ,4346.86,13581.46,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3983.42,100,CUSTOM-DRG,3186.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8078.96,102,MS-DRG,6463.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3983.42,100,CUSTOM-DRG,3186.74,Case rate,100% of GA Medicaid ,7920.55,100,MS-DRG,6336.44,Case rate,100% of Medicare MS-DRG,3983.42,100,CUSTOM-DRG,3186.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3983.42,100,CUSTOM-DRG,3186.74,Case rate,100% of GA Medicaid ,3983.42,8078.96,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9809.51,100,CUSTOM-DRG,7847.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17328.2,102,MS-DRG,13862.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9809.51,100,CUSTOM-DRG,7847.61,Case rate,100% of GA Medicaid ,16988.43,100,MS-DRG,13590.74,Case rate,100% of Medicare MS-DRG,9809.51,100,CUSTOM-DRG,7847.61,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9809.51,100,CUSTOM-DRG,7847.61,Case rate,100% of GA Medicaid ,9809.51,17328.2,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9171.35,102,MS-DRG,7337.08,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,8991.52,100,MS-DRG,7193.22,Case rate,100% of Medicare MS-DRG,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,4298.1,9171.35,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6601.14,102,MS-DRG,5280.91,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,6471.71,100,MS-DRG,5177.37,Case rate,100% of Medicare MS-DRG,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4298.1,100,CUSTOM-DRG,3438.48,Case rate,100% of GA Medicaid ,4298.1,6601.14,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,33120.54,100,CUSTOM-DRG,26496.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,57682.52,102,MS-DRG,46146.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,33120.54,100,CUSTOM-DRG,26496.43,Case rate,100% of GA Medicaid ,56551.49,100,MS-DRG,45241.19,Case rate,100% of Medicare MS-DRG,33120.54,100,CUSTOM-DRG,26496.43,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,33120.54,100,CUSTOM-DRG,26496.43,Case rate,100% of GA Medicaid ,33120.54,57682.52,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,7,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,101588.96,102,MS-DRG,81271.17,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,99597.02,100,MS-DRG,79677.62,Case rate,100% of Medicare MS-DRG,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,55328.52,100,CUSTOM-DRG,44262.82,Case rate,100% of GA Medicaid ,55328.52,101588.96,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5514.73,100,CUSTOM-DRG,4411.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8809.38,102,MS-DRG,7047.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5514.73,100,CUSTOM-DRG,4411.78,Case rate,100% of GA Medicaid ,8636.65,100,MS-DRG,6909.32,Case rate,100% of Medicare MS-DRG,5514.73,100,CUSTOM-DRG,4411.78,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5514.73,100,CUSTOM-DRG,4411.78,Case rate,100% of GA Medicaid ,5514.73,8809.38,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30903.87,102,MS-DRG,24723.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,30297.91,100,MS-DRG,24238.33,Case rate,100% of Medicare MS-DRG,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10852.74,100,CUSTOM-DRG,8682.19,Case rate,100% of GA Medicaid ,10852.74,30903.87,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3428.29,100,CUSTOM-DRG,2742.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8319.18,102,MS-DRG,6655.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3428.29,100,CUSTOM-DRG,2742.63,Case rate,100% of GA Medicaid ,8156.06,100,MS-DRG,6524.85,Case rate,100% of Medicare MS-DRG,3428.29,100,CUSTOM-DRG,2742.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3428.29,100,CUSTOM-DRG,2742.63,Case rate,100% of GA Medicaid ,3428.29,8319.18,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2957.37,100,CUSTOM-DRG,2365.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8006.04,102,MS-DRG,6404.83,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2957.37,100,CUSTOM-DRG,2365.9,Case rate,100% of GA Medicaid ,7849.06,100,MS-DRG,6279.25,Case rate,100% of Medicare MS-DRG,2957.37,100,CUSTOM-DRG,2365.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2957.37,100,CUSTOM-DRG,2365.9,Case rate,100% of GA Medicaid ,2957.37,8006.04,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3046.57,100,CUSTOM-DRG,2437.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8219.58,102,MS-DRG,6575.66,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3046.57,100,CUSTOM-DRG,2437.26,Case rate,100% of GA Medicaid ,8058.41,100,MS-DRG,6446.73,Case rate,100% of Medicare MS-DRG,3046.57,100,CUSTOM-DRG,2437.26,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3046.57,100,CUSTOM-DRG,2437.26,Case rate,100% of GA Medicaid ,3046.57,8219.58,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4368.46,100,CUSTOM-DRG,3494.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15531.86,102,MS-DRG,12425.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4368.46,100,CUSTOM-DRG,3494.77,Case rate,100% of GA Medicaid ,15227.31,100,MS-DRG,12181.85,Case rate,100% of Medicare MS-DRG,4368.46,100,CUSTOM-DRG,3494.77,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4368.46,100,CUSTOM-DRG,3494.77,Case rate,100% of GA Medicaid ,4368.46,15531.86,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6209.48,100,CUSTOM-DRG,4967.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14550.45,102,MS-DRG,11640.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6209.48,100,CUSTOM-DRG,4967.58,Case rate,100% of GA Medicaid ,14265.15,100,MS-DRG,11412.12,Case rate,100% of Medicare MS-DRG,6209.48,100,CUSTOM-DRG,4967.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6209.48,100,CUSTOM-DRG,4967.58,Case rate,100% of GA Medicaid ,6209.48,14550.45,
PSYCHOSES,885,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11316.37,102,MS-DRG,9053.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,11094.48,100,MS-DRG,8875.58,Case rate,100% of Medicare MS-DRG,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4001.7,100,CUSTOM-DRG,3201.36,Case rate,100% of GA Medicaid ,4001.7,11316.37,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3167.34,100,CUSTOM-DRG,2533.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13927.65,102,MS-DRG,11142.12,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3167.34,100,CUSTOM-DRG,2533.87,Case rate,100% of GA Medicaid ,13654.56,100,MS-DRG,10923.65,Case rate,100% of Medicare MS-DRG,3167.34,100,CUSTOM-DRG,2533.87,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3167.34,100,CUSTOM-DRG,2533.87,Case rate,100% of GA Medicaid ,3167.34,13927.65,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3296.98,100,CUSTOM-DRG,2637.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10730.02,102,MS-DRG,8584.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3296.98,100,CUSTOM-DRG,2637.58,Case rate,100% of GA Medicaid ,10519.63,100,MS-DRG,8415.7,Case rate,100% of Medicare MS-DRG,3296.98,100,CUSTOM-DRG,2637.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3296.98,100,CUSTOM-DRG,2637.58,Case rate,100% of GA Medicaid ,3296.98,10730.02,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3200.03,100,CUSTOM-DRG,2560.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5844.67,102,MS-DRG,4675.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3200.03,100,CUSTOM-DRG,2560.02,Case rate,100% of GA Medicaid ,5730.07,100,MS-DRG,4584.06,Case rate,100% of Medicare MS-DRG,3200.03,100,CUSTOM-DRG,2560.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3200.03,100,CUSTOM-DRG,2560.02,Case rate,100% of GA Medicaid ,3200.03,5844.67,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2448.78,100,CUSTOM-DRG,1959.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13323.89,102,MS-DRG,10659.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2448.78,100,CUSTOM-DRG,1959.02,Case rate,100% of GA Medicaid ,13062.64,100,MS-DRG,10450.11,Case rate,100% of Medicare MS-DRG,2448.78,100,CUSTOM-DRG,1959.02,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2448.78,100,CUSTOM-DRG,1959.02,Case rate,100% of GA Medicaid ,2448.78,13323.89,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7744.67,100,CUSTOM-DRG,6195.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14726.04,102,MS-DRG,11780.83,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7744.67,100,CUSTOM-DRG,6195.74,Case rate,100% of GA Medicaid ,14437.29,100,MS-DRG,11549.83,Case rate,100% of Medicare MS-DRG,7744.67,100,CUSTOM-DRG,6195.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7744.67,100,CUSTOM-DRG,6195.74,Case rate,100% of GA Medicaid ,7744.67,14726.04,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,7674.67,102,MS-DRG,6139.74,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7524.19,100,MS-DRG,6019.35,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,7524.19,7674.67,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17020.66,100,CUSTOM-DRG,13616.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,35842.36,102,MS-DRG,28673.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,17020.66,100,CUSTOM-DRG,13616.53,Case rate,100% of GA Medicaid ,35139.57,100,MS-DRG,28111.66,Case rate,100% of Medicare MS-DRG,17020.66,100,CUSTOM-DRG,13616.53,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17020.66,100,CUSTOM-DRG,13616.53,Case rate,100% of GA Medicaid ,17020.66,35842.36,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7641.63,100,CUSTOM-DRG,6113.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15608.88,102,MS-DRG,12487.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7641.63,100,CUSTOM-DRG,6113.3,Case rate,100% of GA Medicaid ,15302.82,100,MS-DRG,12242.26,Case rate,100% of Medicare MS-DRG,7641.63,100,CUSTOM-DRG,6113.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7641.63,100,CUSTOM-DRG,6113.3,Case rate,100% of GA Medicaid ,7641.63,15608.88,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5545.21,100,CUSTOM-DRG,4436.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10281.97,102,MS-DRG,8225.58,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5545.21,100,CUSTOM-DRG,4436.17,Case rate,100% of GA Medicaid ,10080.36,100,MS-DRG,8064.29,Case rate,100% of Medicare MS-DRG,5545.21,100,CUSTOM-DRG,4436.17,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5545.21,100,CUSTOM-DRG,4436.17,Case rate,100% of GA Medicaid ,5545.21,10281.97,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14590.72,100,CUSTOM-DRG,11672.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26967.49,102,MS-DRG,21573.99,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14590.72,100,CUSTOM-DRG,11672.58,Case rate,100% of GA Medicaid ,26438.72,100,MS-DRG,21150.98,Case rate,100% of Medicare MS-DRG,14590.72,100,CUSTOM-DRG,11672.58,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14590.72,100,CUSTOM-DRG,11672.58,Case rate,100% of GA Medicaid ,14590.72,26967.49,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13116.04,102,MS-DRG,10492.83,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,12858.86,100,MS-DRG,10287.09,Case rate,100% of Medicare MS-DRG,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7664.89,100,CUSTOM-DRG,6131.91,Case rate,100% of GA Medicaid ,7664.89,13116.04,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5829.97,100,CUSTOM-DRG,4663.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15583.2,102,MS-DRG,12466.56,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5829.97,100,CUSTOM-DRG,4663.98,Case rate,100% of GA Medicaid ,15277.65,100,MS-DRG,12222.12,Case rate,100% of Medicare MS-DRG,5829.97,100,CUSTOM-DRG,4663.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5829.97,100,CUSTOM-DRG,4663.98,Case rate,100% of GA Medicaid ,5829.97,15583.2,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24103.28,100,CUSTOM-DRG,19282.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30804.49,102,MS-DRG,24643.59,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,24103.28,100,CUSTOM-DRG,19282.62,Case rate,100% of GA Medicaid ,30200.48,100,MS-DRG,24160.38,Case rate,100% of Medicare MS-DRG,24103.28,100,CUSTOM-DRG,19282.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24103.28,100,CUSTOM-DRG,19282.62,Case rate,100% of GA Medicaid ,24103.28,30804.49,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9704.25,100,CUSTOM-DRG,7763.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16597.74,102,MS-DRG,13278.19,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9704.25,100,CUSTOM-DRG,7763.4,Case rate,100% of GA Medicaid ,16272.29,100,MS-DRG,13017.83,Case rate,100% of Medicare MS-DRG,9704.25,100,CUSTOM-DRG,7763.4,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9704.25,100,CUSTOM-DRG,7763.4,Case rate,100% of GA Medicaid ,9704.25,16597.74,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6793.42,100,CUSTOM-DRG,5434.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11232.73,102,MS-DRG,8986.18,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6793.42,100,CUSTOM-DRG,5434.74,Case rate,100% of GA Medicaid ,11012.48,100,MS-DRG,8809.98,Case rate,100% of Medicare MS-DRG,6793.42,100,CUSTOM-DRG,5434.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6793.42,100,CUSTOM-DRG,5434.74,Case rate,100% of GA Medicaid ,6793.42,11232.73,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6284.27,100,CUSTOM-DRG,5027.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12377.29,102,MS-DRG,9901.83,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6284.27,100,CUSTOM-DRG,5027.42,Case rate,100% of GA Medicaid ,12134.6,100,MS-DRG,9707.68,Case rate,100% of Medicare MS-DRG,6284.27,100,CUSTOM-DRG,5027.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6284.27,100,CUSTOM-DRG,5027.42,Case rate,100% of GA Medicaid ,6284.27,12377.29,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3826.08,100,CUSTOM-DRG,3060.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8013.85,102,MS-DRG,6411.08,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3826.08,100,CUSTOM-DRG,3060.86,Case rate,100% of GA Medicaid ,7856.72,100,MS-DRG,6285.38,Case rate,100% of Medicare MS-DRG,3826.08,100,CUSTOM-DRG,3060.86,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3826.08,100,CUSTOM-DRG,3060.86,Case rate,100% of GA Medicaid ,3826.08,8013.85,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8864.35,100,CUSTOM-DRG,7091.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14692.06,102,MS-DRG,11753.65,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8864.35,100,CUSTOM-DRG,7091.48,Case rate,100% of GA Medicaid ,14403.98,100,MS-DRG,11523.18,Case rate,100% of Medicare MS-DRG,8864.35,100,CUSTOM-DRG,7091.48,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8864.35,100,CUSTOM-DRG,7091.48,Case rate,100% of GA Medicaid ,8864.35,14692.06,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3427.73,100,CUSTOM-DRG,2742.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6393.47,102,MS-DRG,5114.78,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3427.73,100,CUSTOM-DRG,2742.18,Case rate,100% of GA Medicaid ,6268.11,100,MS-DRG,5014.49,Case rate,100% of Medicare MS-DRG,3427.73,100,CUSTOM-DRG,2742.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3427.73,100,CUSTOM-DRG,2742.18,Case rate,100% of GA Medicaid ,3427.73,6393.47,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6991.76,100,CUSTOM-DRG,5593.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13217.06,102,MS-DRG,10573.65,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6991.76,100,CUSTOM-DRG,5593.41,Case rate,100% of GA Medicaid ,12957.9,100,MS-DRG,10366.32,Case rate,100% of Medicare MS-DRG,6991.76,100,CUSTOM-DRG,5593.41,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6991.76,100,CUSTOM-DRG,5593.41,Case rate,100% of GA Medicaid ,6991.76,13217.06,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7709.18,102,MS-DRG,6167.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,7558.02,100,MS-DRG,6046.42,Case rate,100% of Medicare MS-DRG,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,3645.46,100,CUSTOM-DRG,2916.37,Case rate,100% of GA Medicaid ,3645.46,7709.18,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6592.31,100,CUSTOM-DRG,5273.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15111.96,102,MS-DRG,12089.57,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6592.31,100,CUSTOM-DRG,5273.85,Case rate,100% of GA Medicaid ,14815.65,100,MS-DRG,11852.52,Case rate,100% of Medicare MS-DRG,6592.31,100,CUSTOM-DRG,5273.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6592.31,100,CUSTOM-DRG,5273.85,Case rate,100% of GA Medicaid ,6592.31,15111.96,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6084.27,100,CUSTOM-DRG,4867.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8834.78,102,MS-DRG,7067.82,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6084.27,100,CUSTOM-DRG,4867.42,Case rate,100% of GA Medicaid ,8661.55,100,MS-DRG,6929.24,Case rate,100% of Medicare MS-DRG,6084.27,100,CUSTOM-DRG,4867.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6084.27,100,CUSTOM-DRG,4867.42,Case rate,100% of GA Medicaid ,6084.27,8834.78,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4196.16,100,CUSTOM-DRG,3356.93,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6647.38,102,MS-DRG,5317.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4196.16,100,CUSTOM-DRG,3356.93,Case rate,100% of GA Medicaid ,6517.04,100,MS-DRG,5213.63,Case rate,100% of Medicare MS-DRG,4196.16,100,CUSTOM-DRG,3356.93,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4196.16,100,CUSTOM-DRG,3356.93,Case rate,100% of GA Medicaid ,4196.16,6647.38,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7424.45,100,CUSTOM-DRG,5939.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14451.06,102,MS-DRG,11560.85,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7424.45,100,CUSTOM-DRG,5939.56,Case rate,100% of GA Medicaid ,14167.71,100,MS-DRG,11334.17,Case rate,100% of Medicare MS-DRG,7424.45,100,CUSTOM-DRG,5939.56,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7424.45,100,CUSTOM-DRG,5939.56,Case rate,100% of GA Medicaid ,7424.45,14451.06,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4358.49,100,CUSTOM-DRG,3486.79,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8688.95,102,MS-DRG,6951.16,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4358.49,100,CUSTOM-DRG,3486.79,Case rate,100% of GA Medicaid ,8518.58,100,MS-DRG,6814.86,Case rate,100% of Medicare MS-DRG,4358.49,100,CUSTOM-DRG,3486.79,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4358.49,100,CUSTOM-DRG,3486.79,Case rate,100% of GA Medicaid ,4358.49,8688.95,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,75124.28,100,CUSTOM-DRG,60099.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,218299.83,102,MS-DRG,174639.86,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,75124.28,100,CUSTOM-DRG,60099.42,Case rate,100% of GA Medicaid ,214019.44,100,MS-DRG,171215.55,Case rate,100% of Medicare MS-DRG,75124.28,100,CUSTOM-DRG,60099.42,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,75124.28,100,CUSTOM-DRG,60099.42,Case rate,100% of GA Medicaid ,75124.28,218299.83,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12391.81,100,CUSTOM-DRG,9913.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,57308.19,102,MS-DRG,45846.55,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12391.81,100,CUSTOM-DRG,9913.45,Case rate,100% of GA Medicaid ,56184.5,100,MS-DRG,44947.6,Case rate,100% of Medicare MS-DRG,12391.81,100,CUSTOM-DRG,9913.45,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12391.81,100,CUSTOM-DRG,9913.45,Case rate,100% of GA Medicaid ,12391.81,57308.19,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5925.82,100,CUSTOM-DRG,4740.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26630.43,102,MS-DRG,21304.34,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5925.82,100,CUSTOM-DRG,4740.66,Case rate,100% of GA Medicaid ,26108.26,100,MS-DRG,20886.61,Case rate,100% of Medicare MS-DRG,5925.82,100,CUSTOM-DRG,4740.66,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5925.82,100,CUSTOM-DRG,4740.66,Case rate,100% of GA Medicaid ,5925.82,26630.43,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20303.8,100,CUSTOM-DRG,16243.04,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,25110.69,102,MS-DRG,20088.55,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,20303.8,100,CUSTOM-DRG,16243.04,Case rate,100% of GA Medicaid ,24618.32,100,MS-DRG,19694.66,Case rate,100% of Medicare MS-DRG,20303.8,100,CUSTOM-DRG,16243.04,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20303.8,100,CUSTOM-DRG,16243.04,Case rate,100% of GA Medicaid ,20303.8,25110.69,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5326.92,100,CUSTOM-DRG,4261.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17329.86,102,MS-DRG,13863.89,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5326.92,100,CUSTOM-DRG,4261.54,Case rate,100% of GA Medicaid ,16990.06,100,MS-DRG,13592.05,Case rate,100% of Medicare MS-DRG,5326.92,100,CUSTOM-DRG,4261.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5326.92,100,CUSTOM-DRG,4261.54,Case rate,100% of GA Medicaid ,5326.92,17329.86,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4789.52,100,CUSTOM-DRG,3831.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16904.16,102,MS-DRG,13523.33,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4789.52,100,CUSTOM-DRG,3831.62,Case rate,100% of GA Medicaid ,16572.71,100,MS-DRG,13258.17,Case rate,100% of Medicare MS-DRG,4789.52,100,CUSTOM-DRG,3831.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4789.52,100,CUSTOM-DRG,3831.62,Case rate,100% of GA Medicaid ,4789.52,16904.16,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14717.04,100,CUSTOM-DRG,11773.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,26628.76,102,MS-DRG,21303.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,14717.04,100,CUSTOM-DRG,11773.63,Case rate,100% of GA Medicaid ,26106.63,100,MS-DRG,20885.3,Case rate,100% of Medicare MS-DRG,14717.04,100,CUSTOM-DRG,11773.63,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14717.04,100,CUSTOM-DRG,11773.63,Case rate,100% of GA Medicaid ,14717.04,26628.76,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9721.42,100,CUSTOM-DRG,7777.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,17943.55,102,MS-DRG,14354.84,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9721.42,100,CUSTOM-DRG,7777.14,Case rate,100% of GA Medicaid ,17591.72,100,MS-DRG,14073.38,Case rate,100% of Medicare MS-DRG,9721.42,100,CUSTOM-DRG,7777.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9721.42,100,CUSTOM-DRG,7777.14,Case rate,100% of GA Medicaid ,9721.42,17943.55,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7352.98,100,CUSTOM-DRG,5882.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15371.19,102,MS-DRG,12296.95,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7352.98,100,CUSTOM-DRG,5882.38,Case rate,100% of GA Medicaid ,15069.79,100,MS-DRG,12055.83,Case rate,100% of Medicare MS-DRG,7352.98,100,CUSTOM-DRG,5882.38,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7352.98,100,CUSTOM-DRG,5882.38,Case rate,100% of GA Medicaid ,7352.98,15371.19,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19688.28,100,CUSTOM-DRG,15750.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12501.52,102,MS-DRG,10001.22,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19688.28,100,CUSTOM-DRG,15750.62,Case rate,100% of GA Medicaid ,12256.39,100,MS-DRG,9805.11,Case rate,100% of Medicare MS-DRG,19688.28,100,CUSTOM-DRG,15750.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19688.28,100,CUSTOM-DRG,15750.62,Case rate,100% of GA Medicaid ,12256.39,19688.28,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4481.48,100,CUSTOM-DRG,3585.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8697.42,102,MS-DRG,6957.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4481.48,100,CUSTOM-DRG,3585.18,Case rate,100% of GA Medicaid ,8526.88,100,MS-DRG,6821.5,Case rate,100% of Medicare MS-DRG,4481.48,100,CUSTOM-DRG,3585.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4481.48,100,CUSTOM-DRG,3585.18,Case rate,100% of GA Medicaid ,4481.48,8697.42,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8463.79,100,CUSTOM-DRG,6771.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10365.62,102,MS-DRG,8292.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,8463.79,100,CUSTOM-DRG,6771.03,Case rate,100% of GA Medicaid ,10162.37,100,MS-DRG,8129.9,Case rate,100% of Medicare MS-DRG,8463.79,100,CUSTOM-DRG,6771.03,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8463.79,100,CUSTOM-DRG,6771.03,Case rate,100% of GA Medicaid ,8463.79,10365.62,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4557.94,100,CUSTOM-DRG,3646.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7319.22,102,MS-DRG,5855.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4557.94,100,CUSTOM-DRG,3646.35,Case rate,100% of GA Medicaid ,7175.71,100,MS-DRG,5740.57,Case rate,100% of Medicare MS-DRG,4557.94,100,CUSTOM-DRG,3646.35,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4557.94,100,CUSTOM-DRG,3646.35,Case rate,100% of GA Medicaid ,4557.94,7319.22,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12199.01,100,CUSTOM-DRG,9759.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9088.68,102,MS-DRG,7270.94,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12199.01,100,CUSTOM-DRG,9759.21,Case rate,100% of GA Medicaid ,8910.47,100,MS-DRG,7128.38,Case rate,100% of Medicare MS-DRG,12199.01,100,CUSTOM-DRG,9759.21,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12199.01,100,CUSTOM-DRG,9759.21,Case rate,100% of GA Medicaid ,8910.47,12199.01,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4260.43,100,CUSTOM-DRG,3408.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6261.96,102,MS-DRG,5009.57,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4260.43,100,CUSTOM-DRG,3408.34,Case rate,100% of GA Medicaid ,6139.18,100,MS-DRG,4911.34,Case rate,100% of Medicare MS-DRG,4260.43,100,CUSTOM-DRG,3408.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4260.43,100,CUSTOM-DRG,3408.34,Case rate,100% of GA Medicaid ,4260.43,6261.96,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,2826.62,100,CUSTOM-DRG,2261.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5945.59,102,MS-DRG,4756.47,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,2826.62,100,CUSTOM-DRG,2261.3,Case rate,100% of GA Medicaid ,5829.01,100,MS-DRG,4663.21,Case rate,100% of Medicare MS-DRG,2826.62,100,CUSTOM-DRG,2261.3,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,2826.62,100,CUSTOM-DRG,2261.3,Case rate,100% of GA Medicaid ,2826.62,5945.59,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,32940.49,100,CUSTOM-DRG,26352.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,50438.36,102,MS-DRG,40350.69,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,32940.49,100,CUSTOM-DRG,26352.39,Case rate,100% of GA Medicaid ,49449.37,100,MS-DRG,39559.5,Case rate,100% of Medicare MS-DRG,32940.49,100,CUSTOM-DRG,26352.39,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32940.49,100,CUSTOM-DRG,26352.39,Case rate,100% of GA Medicaid ,32940.49,50438.36,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30949.89,100,CUSTOM-DRG,24759.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,32118.82,102,MS-DRG,25695.06,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,30949.89,100,CUSTOM-DRG,24759.91,Case rate,100% of GA Medicaid ,31489.04,100,MS-DRG,25191.23,Case rate,100% of Medicare MS-DRG,30949.89,100,CUSTOM-DRG,24759.91,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,30949.89,100,CUSTOM-DRG,24759.91,Case rate,100% of GA Medicaid ,30949.89,32118.82,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,46928.43,100,CUSTOM-DRG,37542.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,59898.76,102,MS-DRG,47919.01,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,46928.43,100,CUSTOM-DRG,37542.74,Case rate,100% of GA Medicaid ,58724.27,100,MS-DRG,46979.42,Case rate,100% of Medicare MS-DRG,46928.43,100,CUSTOM-DRG,37542.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,46928.43,100,CUSTOM-DRG,37542.74,Case rate,100% of GA Medicaid ,46928.43,59898.76,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19335.92,100,CUSTOM-DRG,15468.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,33498.59,102,MS-DRG,26798.87,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,19335.92,100,CUSTOM-DRG,15468.74,Case rate,100% of GA Medicaid ,32841.75,100,MS-DRG,26273.4,Case rate,100% of Medicare MS-DRG,19335.92,100,CUSTOM-DRG,15468.74,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,19335.92,100,CUSTOM-DRG,15468.74,Case rate,100% of GA Medicaid ,19335.92,33498.59,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11909.81,100,CUSTOM-DRG,9527.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20973.05,102,MS-DRG,16778.44,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,11909.81,100,CUSTOM-DRG,9527.85,Case rate,100% of GA Medicaid ,20561.81,100,MS-DRG,16449.45,Case rate,100% of Medicare MS-DRG,11909.81,100,CUSTOM-DRG,9527.85,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11909.81,100,CUSTOM-DRG,9527.85,Case rate,100% of GA Medicaid ,11909.81,20973.05,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18007.38,100,CUSTOM-DRG,14405.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22645.18,102,MS-DRG,18116.14,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,18007.38,100,CUSTOM-DRG,14405.9,Case rate,100% of GA Medicaid ,22201.16,100,MS-DRG,17760.93,Case rate,100% of Medicare MS-DRG,18007.38,100,CUSTOM-DRG,14405.9,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,18007.38,100,CUSTOM-DRG,14405.9,Case rate,100% of GA Medicaid ,18007.38,22645.18,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10085.42,100,CUSTOM-DRG,8068.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12431.12,102,MS-DRG,9944.9,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,10085.42,100,CUSTOM-DRG,8068.34,Case rate,100% of GA Medicaid ,12187.37,100,MS-DRG,9749.9,Case rate,100% of Medicare MS-DRG,10085.42,100,CUSTOM-DRG,8068.34,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,10085.42,100,CUSTOM-DRG,8068.34,Case rate,100% of GA Medicaid ,10085.42,12431.12,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5008.36,100,CUSTOM-DRG,4006.69,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,8327.64,102,MS-DRG,6662.11,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5008.36,100,CUSTOM-DRG,4006.69,Case rate,100% of GA Medicaid ,8164.35,100,MS-DRG,6531.48,Case rate,100% of Medicare MS-DRG,5008.36,100,CUSTOM-DRG,4006.69,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5008.36,100,CUSTOM-DRG,4006.69,Case rate,100% of GA Medicaid ,5008.36,8327.64,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23840.67,100,CUSTOM-DRG,19072.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,56918.11,102,MS-DRG,45534.49,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,23840.67,100,CUSTOM-DRG,19072.54,Case rate,100% of GA Medicaid ,55802.07,100,MS-DRG,44641.66,Case rate,100% of Medicare MS-DRG,23840.67,100,CUSTOM-DRG,19072.54,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23840.67,100,CUSTOM-DRG,19072.54,Case rate,100% of GA Medicaid ,23840.67,56918.11,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16024.53,100,CUSTOM-DRG,12819.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,23020.34,102,MS-DRG,18416.27,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,16024.53,100,CUSTOM-DRG,12819.62,Case rate,100% of GA Medicaid ,22568.96,100,MS-DRG,18055.17,Case rate,100% of Medicare MS-DRG,16024.53,100,CUSTOM-DRG,12819.62,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,16024.53,100,CUSTOM-DRG,12819.62,Case rate,100% of GA Medicaid ,16024.53,23020.34,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15623.97,100,CUSTOM-DRG,12499.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,24154.13,102,MS-DRG,19323.3,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,15623.97,100,CUSTOM-DRG,12499.18,Case rate,100% of GA Medicaid ,23680.52,100,MS-DRG,18944.42,Case rate,100% of Medicare MS-DRG,15623.97,100,CUSTOM-DRG,12499.18,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,15623.97,100,CUSTOM-DRG,12499.18,Case rate,100% of GA Medicaid ,15623.97,24154.13,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11290.71,102,MS-DRG,9032.57,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,11069.32,100,MS-DRG,8855.46,Case rate,100% of Medicare MS-DRG,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6600.06,100,CUSTOM-DRG,5280.05,Case rate,100% of GA Medicaid ,6600.06,11290.71,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4855.45,100,CUSTOM-DRG,3884.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7607.62,102,MS-DRG,6086.1,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,4855.45,100,CUSTOM-DRG,3884.36,Case rate,100% of GA Medicaid ,7458.45,100,MS-DRG,5966.76,Case rate,100% of Medicare MS-DRG,4855.45,100,CUSTOM-DRG,3884.36,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,4855.45,100,CUSTOM-DRG,3884.36,Case rate,100% of GA Medicaid ,4855.45,7607.62,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6722.5,100,CUSTOM-DRG,5378,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,11727.98,102,MS-DRG,9382.38,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,6722.5,100,CUSTOM-DRG,5378,Case rate,100% of GA Medicaid ,11498.02,100,MS-DRG,9198.42,Case rate,100% of Medicare MS-DRG,6722.5,100,CUSTOM-DRG,5378,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,6722.5,100,CUSTOM-DRG,5378,Case rate,100% of GA Medicaid ,6722.5,11727.98,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28107.2,100,CUSTOM-DRG,22485.76,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,39259.46,102,MS-DRG,31407.57,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,28107.2,100,CUSTOM-DRG,22485.76,Case rate,100% of GA Medicaid ,38489.67,100,MS-DRG,30791.74,Case rate,100% of Medicare MS-DRG,28107.2,100,CUSTOM-DRG,22485.76,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,28107.2,100,CUSTOM-DRG,22485.76,Case rate,100% of GA Medicaid ,28107.2,39259.46,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12735.3,100,CUSTOM-DRG,10188.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,20588.78,102,MS-DRG,16471.02,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,12735.3,100,CUSTOM-DRG,10188.24,Case rate,100% of GA Medicaid ,20185.08,100,MS-DRG,16148.06,Case rate,100% of Medicare MS-DRG,12735.3,100,CUSTOM-DRG,10188.24,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,12735.3,100,CUSTOM-DRG,10188.24,Case rate,100% of GA Medicaid ,12735.3,20588.78,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7725.84,100,CUSTOM-DRG,6180.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,13542.55,102,MS-DRG,10834.04,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,7725.84,100,CUSTOM-DRG,6180.67,Case rate,100% of GA Medicaid ,13277.01,100,MS-DRG,10621.61,Case rate,100% of Medicare MS-DRG,7725.84,100,CUSTOM-DRG,6180.67,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,7725.84,100,CUSTOM-DRG,6180.67,Case rate,100% of GA Medicaid ,7725.84,13542.55,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22063.93,100,CUSTOM-DRG,17651.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,27965.45,102,MS-DRG,22372.36,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,22063.93,100,CUSTOM-DRG,17651.14,Case rate,100% of GA Medicaid ,27417.11,100,MS-DRG,21933.69,Case rate,100% of Medicare MS-DRG,22063.93,100,CUSTOM-DRG,17651.14,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,22063.93,100,CUSTOM-DRG,17651.14,Case rate,100% of GA Medicaid ,22063.93,27965.45,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9639.98,100,CUSTOM-DRG,7711.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,14054.38,102,MS-DRG,11243.5,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,9639.98,100,CUSTOM-DRG,7711.98,Case rate,100% of GA Medicaid ,13778.8,100,MS-DRG,11023.04,Case rate,100% of Medicare MS-DRG,9639.98,100,CUSTOM-DRG,7711.98,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9639.98,100,CUSTOM-DRG,7711.98,Case rate,100% of GA Medicaid ,9639.98,14054.38,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,9137.5,102,MS-DRG,7310,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,8958.33,100,MS-DRG,7166.66,Case rate,100% of Medicare MS-DRG,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,,,,,Other ,Not Seprately reimbursable,5397.28,100,CUSTOM-DRG,4317.82,Case rate,100% of GA Medicaid ,5397.28,9137.5,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,2104.59,102,MS-DRG,1683.67,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,2063.32,100,MS-DRG,1650.66,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,2063.32,2104.59,
UNGROUPABLE,999,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,2104.59,102,MS-DRG,1683.67,Case rate,102% of Medicare MS-DRG,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,2063.32,100,MS-DRG,1650.66,Case rate,100% of Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other ,Not Seprately reimbursable,,,,,Other,Not Separately reimbursable,2063.32,2104.59,